Table 1.

GEAR's exercise and rehabilitation guidelines for prescribing regimes to patients.

Exercise type	Exercise and rehabilitation
Aerobic	• F−4–7 days/week • I—RPE of 3–6/10 (moderate to vigorous) • T−10-30 minutes/session (150 min/week) • T—Walking (progress or regress based on symptoms or patient preference) Notes: • Duration, intensity and type of aerobic exercise will be decreased if onset of orthostatic symptoms occur in more upright postures • When able, incorporate a 5–10 min warm up/cool down with RPE 1–2 • See “Aerobic Training Protocols” for session specific details/guidance
Neuromuscular stabilization	• F—Daily or at least 5 days a week (there are no guidelines on neuromotor exercise intensity for this age group—this recommendation is based on the expectation that frequent practice will result in improved neuromuscular connections, movement patterning and proprioception). • I- RPE 3–6/10 (there are no guidelines on neuromotor exercise intensity—we are replicating the guidelines used to determine intensity for aerobic and resistance exercise) • T−3–6 exercises, depending on the patient's efficiency with neuromuscular control • T—See below for operational definition of Neuromuscular Exercise. Notes: • Neuromuscular exercise: to improve muscle control and stability of the joint, which leads to reduction in symptoms and improved quality of life • Neuromuscular exercises are taught and trained prior to the introduction of resistance-based exercises to ensure effective muscle activation, joint stabilization and posture prior to increasing demand on the patient • Patients are quickly transitioned to resistance-based exercises as they develop adequate activity and postural control involving problematic muscle groups • See “Table 2” for session specific details
Resistance	• F−2-4 days/week • I—RPE 3–6/10 • T−3–6 exercises, 1–3 sets/exercise, 8–15 repetitions/set (10–15 min/session) • T—Start in more supportive postures (lying, seated) using body weight or light resistance and progress to more demanding postures with greater resistance (bands, weights) Notes: • Use neuromuscular exercise principles to maintain good posture and proprioception to avoid aberrant movement patterns (i.e., joint hyperextension) • Monitor for orthostatic symptoms during exercise (e.g., presyncope) • Organize program to avoid multiple transitions from lying, seated or standing • See “Table 2” for more session specific details
Stretching and relaxation	• Encourage and/or support dynamic movements/range of motion exercises within normative values to reduce pain and as a warmup prior to aerobic/strengthening/neuromotor exercises
Balance and proprioception	• Encourage and/or support incorporation of activities that challenge alignment, body awareness and posture
Modification principles
Progression of Exercise	Patients are shown progressions for each exercise and educated on when and how to progress based on RPE Patients can typically start a progression with RPE is consistently <3/10 and as long as any increase in baseline pain decreases within 2 h after ceasing the exercise • Patients are first encouraged to progress the number of repetitions within a set, then the number of sets, in order to build endurance before moving onto a new version of the exercise • Exercise difficulty is increased by changing level of resistance, patient position or a combination of both
Regression of exercise	Patients are shown regressions for each exercise and educated on when and how to regress based on RPE • Patients are encouraged to regress when RPE is > 6/10 or increased pain persists 2 h after ceasing the exercise (28) • Patients are also encouraged to regress to a less effortful version of their program following a flare or acute injury
General	• General progression guidelines go from closed kinetic chain to open kinetic chain, non-weight bearing to weight bearing positions, mid-range to through-range, bilateral to unilateral, short to long lever, reducing base of support, activities within base of support to challenging the limits of stability, introducing unstable surfaces or cognitive tasks • Furthermore, exercises can be modified by changing the number of reps/sets, changing positions or supportive equipment, intensity, number of rest breaks, or changing the exercise all together (progression/regression) • For patients with significant joint instability limiting participation, they are encouraged to wear splints/braces/external supports for the duration of the activity • Patients are encouraged to use prescribed gait aids for walking programs if needed