Early mobilization is a critical component of acute stroke care, aimed at preventing deconditioning, mitigating complications, and promoting early neuroplasticity.¹ However, evidence guiding the optimal frequency, timing, and intensity of inpatient physical therapy (PT) during acute stroke hospitalization remains limited.¹ At the AAN Annual Meeting 2026, Dr. Alexander Vorobyev from the Medical University of South Carolina, United States, presented findings from the BID-FAST project, demonstrating that implementation of twice-daily inpatient PT was associated with significantly shorter hospital length of stay (LOS) without worsening discharge functional outcomes among patients hospitalized with acute stroke.¹

Current American Heart Association/American Stroke Association (AHA/ASA) guidelines provide limited recommendations regarding optimal inpatient PT frequency after acute stroke.¹ Previous studies have also generated mixed findings regarding early mobilization strategies.¹ The AVERT clinical trial reported worse 3-month outcomes with very early high-intensity mobilization initiated within 24 hours after stroke onset, raising concerns regarding excessive early rehabilitation intensity.¹

In contrast, the Frequent Error-Augmentation trial demonstrated improved modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) outcomes using augmented twice-daily PT sessions for 3 of the first 5 hospital days, followed by daily therapy, compared with standard once-daily PT administered 3-5 days per week.¹ Observational studies have similarly suggested that earlier, shorter, and more frequent mobilization after acute ischemic stroke, particularly within the first 3 days, may improve activities of daily living and functional recovery through repetitive, task-specific practice aligned with principles of motor learning and neuroplasticity.¹

To address this clinical gap, the BID-FAST study evaluated whether twice-daily inpatient PT improves outcomes compared with standard PT frequency.¹ The retrospective pre-post cohort study compared 2 consecutive 4-month periods before and after BID-FAST implementation at a comprehensive stroke center, including 155 patients in the standard care cohort and 141 patients in the BID-FAST cohort.¹ Prior to protocol implementation, patients generally received PT 3-5 times weekly with no standardized protocol.¹ Following implementation, clinically stable patients received twice-daily PT sessions lasting approximately 20-40 minutes during at least the first week of hospitalization.¹ Initial PT evaluations continued to be performed within 24 hours after stroke in both cohorts.¹ Primary and secondary outcomes included hospital LOS, discharge mRS, and discharge NIHSS.¹

Implementation of the BID-FAST protocol was associated with a statistically significant reduction in hospital LOS.¹ Median LOS decreased from 6.83 days in the standard care cohort to 4.61 days in the BID-FAST cohort, corresponding to an absolute reduction of 2.22 days (95% CI: 0.57-3.87; p=0.0086).¹ The observed reduction in LOS may be attributable to several mechanisms related to higher-frequency PT.¹ More frequent mobilization may reduce inpatient deconditioning and accelerate recovery, potentially leading to faster discharge readiness.¹ In addition, earlier discharge may also improve hospital efficiency and optimize healthcare resource utilization.¹

Notably, shorter hospitalization duration was not associated with worsening discharge neurological or functional outcomes.¹ Discharge mRS scores were similar between the standard care and BID-FAST cohorts (2.13 vs. 2.07; p=0.777), while discharge NIHSS scores also remained comparable (5.5 vs. 4.8; p=0.90).¹ Similarly, home discharge rates did not differ significantly between groups, occurring in 56.1% of patients in the standard care cohort and 58.2% of patients in the BID-FAST cohort (difference +2.0 percentage points; 95% CI: -9.3 to 13.3; p=0.814).¹ Together, these findings suggest that more frequent inpatient PT may shorten hospitalization without compromising discharge function or disposition outcomes.¹

In summary, findings from the BID-FAST project demonstrated that implementation of twice-daily inpatient PT was associated with significantly shorter hospitalization among patients with acute stroke without adversely affecting discharge neurological function or discharge disposition.¹ These results support therapy frequency as a potentially modifiable factor in acute stroke care.¹ Ongoing prospective studies will help determine which patient populations benefit most from high-frequency inpatient PT and establish an optimal balance of therapy timing and intensity.¹ These studies will also track post-discharge outcomes, including long-term functional status and healthcare resource utilization.¹