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

Abstract

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. 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. 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. 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.