Frequent Error Augmentation Training in Physical Therapy Poststroke: A Phase II

ABSTRACT Introduction: This trial expanded on findings from a Phase I study (Impact of Intense Physical Therapy on Mobility Outcomes in Acute Stroke) to determine whether functional outcomes after acute stroke improve more with increased therapy frequency, error augmentation training, or a combination of both. We hypothesized that patients receiving both increased frequency and error augmentation physical therapy (F-EA-PT) would demonstrate the greatest improvements in mobility and disability from hospital admission through day 3 of treatment, discharge, and 30-day follow-up. Results aim to inform optimal delivery of acute stroke physical therapy to improve length of stay, discharge planning, and long-term recovery. Methods: A total of 102 patients were randomized into 4 groups: standard-of-care physical therapy (SOC-PT, 3–5×/week); increased frequency PT (F-PT, 2×/day); error augmentation PT (EA-PT, 3–5×/week), emphasizing movement errors to challenge impairments; and combined frequency plus error augmentation (F-EA-PT). Outcomes included the Postural Assessment Scale for Stroke (PASS), Activity Measure for Post-Acute Care (AM-PAC), National Institutes of Health Stroke Scale (NIHSS), and modified Rankin Scale. Results: Ninety-two participants were analyzed. Baseline characteristics were similar across groups except for treatment exposure. PASS scores differed significantly at discharge ( P = .023), driven by better performance in the F-EA-PT group compared with SOC-PT (mean difference 6.3; 95% confidence interval, 0.75–11.87; P = .018). No other between-group differences were detected. Mixed-effects models showed significant improvement over time in PASS and AM-PAC across all groups ( P < .001), without significant time-by-group interactions. Predicted probability analysis estimated an 82.6% likelihood of detecting at least 1 significant pairwise contrast had enrollment continued to the original target of 168 participants (42 per arm), compared with the 92 participants included in the final analysis. Conclusions: Early inpatient physical therapy after acute stroke produced significant functional improvements. Although most between-group differences were not significant, combined frequent and error-augmentation therapy showed the greatest gains and superior postural outcomes at discharge. Larger multicenter trials are needed to define optimal therapy dose in acute stroke rehabilitation.