Exercise guide
Exercise is good for people with Down syndrome (also called Down's syndrome) in the same ways it's good for everyone, and strength training has some of the best evidence: in trials, supervised gym sessions twice a week made teenagers and adults stronger, with no serious side effects. Low muscle tone and loose joints are common, so the aim is stronger muscles and better control, not more stretching.
Two things are worth checking. About half of babies with Down syndrome are born with a heart condition, so ask the heart team what activity is safe. And the neck: UK and US guidance no longer recommends routine neck X-rays before sport for people without symptoms, but everyone should know the warning signs. Heart rate also runs lower in Down syndrome, so use the talk test rather than heart rate zones.
This guide covers the evidence, how much to do, strength training, loose joints, the neck, the heart, weight, Special Olympics and clubs, with moves and a gym routine to follow on the 3D figure.
Across 16 randomised trials, resistance training increased strength by a large amount and improved physical function, with no serious side effects. In the main trials, teenagers and young adults trained on gym machines twice a week for 10 weeks, with a buddy who did the routine too.
Exercise programmes improved aerobic fitness in 10 trials, with no side effects reported, and balance improved in small, lower-quality studies.
Low muscle tone and loose ligaments are common, so joints need stronger muscles around them and better control, built up gradually, rather than more range. Our hypermobility guide uses the same approach.
Neck instability is more common in Down syndrome, but serious damage is rare. UK and US guidance advises against routine neck X-rays for people without symptoms, because X-rays don't predict who will have problems, and people without symptoms shouldn't be barred from normal sport. Learn the warning signs, and stop sport and see a doctor if any appear.
About half of babies with Down syndrome are born with a heart condition. If there was one, ask the heart team what level of activity is safe. Breathing difficulties, unusual tiredness, dizziness, faints or chest pain need a doctor, and fainting during exercise needs 999.
Maximum heart rate is lower in Down syndrome, so heart rate zones from age-based formulas aim too high. If you can talk but not sing, you're working at a moderate effort.
Down syndrome is when you're born with an extra chromosome, usually by chance. People with Down syndrome have some level of learning disability and a wide range of abilities, and like everyone they have their own personalities, likes and dislikes. The Down's Syndrome Association says both "Down syndrome" and "Down's syndrome" are fine.
About 37,090 people had Down syndrome in England and Wales in 2011, and many are now in their 40s and 50s. In the US, about 5,775 babies are born with it each year, and average life expectancy there has risen from 25 years in 1983 to about 60.
Low muscle tone and loose ligaments make joints unusually flexible and harder to hold steady, which can affect posture and balance and raise the risk of dislocations. Loose ligaments are close to universal. Related problems include flat feet and ankles that roll in, kneecaps that slip (in 4% to 8%), hip problems and scoliosis.
Muscle strength can be up to 50% lower than in peers, and work capacity and peak fitness are lower too, partly because maximum heart rate is lower, probably from differences in the nerves that control the heart.
About half of children are born with a heart condition, most often a hole between the heart's chambers (a septal defect). Heart problems can also appear later, including valve disease in adults, and high pressure in the lung arteries (pulmonary hypertension) can develop even without a heart defect. Rates of high blood pressure and coronary heart disease seem lower than average.
In children, obstructive sleep apnoea affects 50% to 79%, hearing loss about 75%, and thyroid disease about half by adulthood; autism affects 7% to 19%. About 2 in 100 people with Down syndrome have epilepsy, more if dementia develops. Dementia starts earlier, affecting nearly 9% of adults at 45 to 50 and nearly a third at 55 to 59, and menopause comes about 5 years earlier.
Overweight and obesity affect between 23% and 70% of young people with Down syndrome in different studies, linked with a lower resting metabolic rate, appetite hormones, other conditions, diet and low activity. The Down's Syndrome Association adds an underactive thyroid, sleep apnoea and some medicines, and says weight gain isn't inevitable.
In 17 studies of children and teenagers, ability, competing family demands, overprotective parenting, friends, local programmes and a lack of public support all shaped how active they were. Fewer inclusive programmes, transport and relying on family for lifts make it harder for adults too.
Effect sizes put different scales onto one: about 0.2 is small, 0.5 moderate and 0.8 or more large.
In a review of 16 randomised trials, resistance training increased strength by a large amount (effect size 1.88) and improved physical function (0.58), with no serious side effects; body measurements and aerobic fitness didn't clearly change. Other reviews agree: about 5.7 kg more upper-body and 20.4 kg more lower-body strength in 3 trials with 111 people, and bigger gains in younger people across 8 trials with 127 people.
20 adults (average age 27) did 6 machine exercises twice a week for 10 weeks: their upper-body endurance improved, with trends, not statistically clear, towards stronger arms and faster shelving of groceries. 23 teenagers did a student-led version, came to 90% of sessions and gained 36 kg more leg strength than the comparison group, with no major side effects. 68 young people aged 14 to 22 came to 92% of sessions, were stronger at 11 weeks, and at 24 weeks their legs were still stronger and they were more active. Their work tasks didn't change.
In 10 randomised trials, exercise programmes raised peak oxygen uptake (effect size 0.69) and time to exhaustion (0.83), with no side effects reported, though results varied between trials. An earlier review of 10 trials found clearer effects on strength and balance than on aerobic fitness or body fat.
Across 11 studies at high risk of bias, exercise improved standing balance in children and overall balance in children and teenagers. Across 6 studies, postural control improved (effect size 0.67), with low certainty.
In adults, combined exercise increased upper-body (effect size 0.74) and lower-body (0.56) strength, and aerobic exercise improved walking and balance, with low to moderate certainty. A review of 35 studies found aerobic and strength training improved fitness, strength, weight and body fat.
A review of 19 varied studies (525 people aged 3 to 65) supported exercise for daily activities and taking part in life, but the studies were too different to combine. Strength training didn't clearly change walking or stair climbing in one review, or work tasks in the largest trial.
Exercise programmes on their own haven't reliably reduced weight or fat in young people with Down syndrome, and resistance training didn't clearly change body measurements.
An average of at least 60 minutes a day across the week, with activities that build muscles and bones. The UK guidelines for disabled children say 20 minutes a day brings good health benefits, built up slowly in bitesize chunks, with strength and balance activities 3 times a week.
At least 150 minutes a week of moderate activity, plus strength and balance activities on at least 2 days. "Even a little movement is better than nothing."
"If you are under 18 you should exercise for 1 hour every day", and adults for 30 minutes on 5 days a week, broken into smaller amounts if that's easier. "Don't worry if you can't do much exercise right now." If you haven't exercised before, tell your doctor you want to start.
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There are no official guidelines just for Down syndrome. An expert summary published by the US National Down Syndrome Society suggests at least 30 minutes of aerobic activity a day for children and teenagers, and for adults 150 minutes a week, strength 2 to 3 days a week (2 to 3 sets of 6 to 12), and balance and flexibility 2 to 3 days a week, done with care.
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Child who walks: active play, swimming or a sport most days, building towards an hour, with strength and balance games such as animal moves 3 times a week. Teenager or adult: 2 strength sessions (the gym routine below, or our hypermobility strength and control routine), 3 to 5 sessions of walking, swimming, dancing or sport at a talk-but-not-sing effort, building towards 150 minutes, and a few minutes of balance practice most days.
7 exercises on weight machines: 3 for the upper body (such as a pull-down, a chest press and a seated row), 3 for the lower body (such as a leg press, a knee extension and a seated calf raise) and 1 for the trunk. 3 sets of 12, at a weight that can be lifted only 12 times, twice a week. When 3 sets of 12 are possible, the weight goes up.
The trial used machines because "they are safer for novice participants than free weights". Bodyweight moves at home work too, and the moves below include both.
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In the trials, each young person trained with a student mentor who did the routine as well, doing their set while the other rested and counting together, because people with Down syndrome "are far more likely to exercise when a support person joins in". Attendance was over 9 in 10 sessions.
For the first 2 weeks, do 1 or 2 sets of 10 to 12 with a light weight while you learn each move, then build to 3 sets. The adult trial used 2 to 3 sets of 10 to 12. Demonstrate each exercise in more than one way and check it's done correctly before adding weight.
A physiotherapy programme designed for adults with Down syndrome starts with squats (15, with hand support at first), push-ups on the knees (10), bridges (10, holding each for 5 seconds) and hip lifts to the side (10 each side), plus balance work. It suggests strength work 2 to 3 times a week.
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Physiotherapy for Down syndrome focuses on strengthening the muscles around the joints and improving stability and coordination. The usual advice is to strengthen the core and the muscles that steady the hips, shoulders and knees, and a resistance training review advises extra care because of loose joints and lower bone density.
Do stretches and flexibility work with care, and favour moving through a comfortable range over long, deep stretches. Our editorial rule, as in our hypermobility guide: don't lock your knees or elbows or push into the end of a joint's range.
Flat feet and ankles that roll in are common. Flat feet don't usually need treatment if they're painless; if they hurt, insoles can help, and many people wear supportive footwear. Our foot and ankle routine and flat feet guide can help.
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Kneecaps that slip and hip problems are more common. In teenagers, new knee pain with a limp can come from the hip and needs a doctor the same day (see warning signs).
Loose ligaments and low muscle tone can let the top two bones of the neck move more than usual (atlanto-axial instability). Depending on the study, 10% to 27% of people with Down syndrome have signs of extra movement on X-rays, but symptoms are much rarer (1% to 2% of children), and about 1% need an operation.
Neck X-rays are unreliable and don't predict who will have problems, and a normal X-ray doesn't rule out problems later, so the UK changed its advice in 1995. In a 1993 trial, 91 children whose X-rays showed extra movement were split between carrying on with their usual sport and avoiding "risky" sports; after a year there were no differences between the groups.
UK specialists say people without symptoms "should not be barred from normal sporting activities", with good supervision as for any sport. The American Academy of Pediatrics (AAP) doesn't recommend routine X-rays for children without symptoms, and the US adult guideline says the same for adults: although about 1 in 10 adults has atlanto-axial instability, they don't have a higher risk of spinal cord injury.
Stop sport and see a doctor if any of these appear; get an urgent appointment if they come on suddenly:
The two differ in strength. The UK's Down's Syndrome Association says trampolining, diving, contact sports and high jump carry a higher risk of neck injury for everyone, and that there's no evidence a mini-trampoline, early horse riding or forward rolls carry more risk for a child with Down syndrome and no symptoms. The AAP goes further: it says all children, with or without Down syndrome, should avoid trampolines unless in a supervised, structured programme, and that contact sports such as American football, soccer and gymnastics put children at risk of spinal cord injury.
Special Olympics asks for a medical examination of all athletes, and the Down's Syndrome Association says British Gymnastics and Special Olympics need medical clearance. Rules vary between programmes. Special Olympics Ireland, for example, doesn't allow athletes with Down syndrome to do butterfly stroke, diving starts, high jump, squat lifts, artistic gymnastics, football and some other events unless a doctor's examination, including neck X-rays, finds no instability, or, if it does, the athlete or a parent accepts the risks in writing and two medical professionals confirm they've explained them. Ask your club or Special Olympics programme what they need before you enter.
Our suggestion, from the advice on neck instability: leave out headstands, shoulderstands, the plough and Pilates roll-overs, which put body weight through the head and neck, unless a doctor has checked your neck. There's no direct evidence about these moves; Special Olympics Ireland restricts activities that put direct pressure on the neck or upper spine.
Find out whether there was a heart condition at birth, what it was, whether it was repaired, and whether there's high pressure in the lung arteries. If you're under a heart team, ask them what a safe level of activity is for you. Children should have had a heart scan (echocardiogram) by 6 weeks of age, so most families will know.
From adolescence, the doctor should listen to the heart at routine checks, because valve problems can develop later, and the Down's Syndrome Association says everyone with Down syndrome aged 14 and over is entitled to a free Annual Health Check with their GP. Increasing tiredness, breathlessness on exertion or a new heart murmur need a heart scan. Adults with a heart condition should be followed in an expert centre.
In a study of 276 people with an intellectual disability, 97 of them with Down syndrome, having Down syndrome lowered the predicted maximum heart rate by about 15.5 beats a minute, after allowing for age. So heart rate zones from age-based formulas, including our heart rate calculator, aim too high. Use the talk test instead: talking but not singing is moderate. Our suggestion: only use a heart rate target if a doctor or physiotherapist has set it from an exercise test.
An international expert consensus says "Regular physical activity should be encouraged in all those with DS" (Down syndrome) to support weight management and improve heart fitness and quality of life, with exercise capacity checked from time to time in people with heart disease or high lung pressure.
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Exercise builds strength and fitness, but on its own it hasn't reliably reduced weight in young people with Down syndrome. Food, sleep, health checks and activity work together.
The Down's Syndrome Association suggests simple, regular meals, visual meal plans and portion guides, water instead of sugary drinks, involving the person in planning and cooking, and fun activity built on their interests. Track small wins, such as steps or swapped snacks, and "avoid focusing too heavily on weight numbers".
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If weight is rising, ask about the thyroid and about sleep apnoea, which are both common. The US guidelines ask for weight checks and encourage healthy eating and regular exercise for children and adults.
Demonstrate each exercise and check it's done correctly. Hearing and vision problems are common, so our suggestion is to face the person, use short, clear instructions and add visual cues.
Do activities together so no one feels singled out, celebrate effort, and track active days with stickers or a calendar. The Down's Syndrome Association often hears about weight gain when adults leave home, so building enjoyable active habits early helps.
Overprotective parenting is one of the things that keeps children with Down syndrome less active. For children without neck symptoms, normal sport is encouraged.
The Down's Syndrome Association's DSActive programme supports people to take part "at all levels of ability from local community participation through to national and international level", and DSEngage runs free online sessions. Special Olympics GB offers 27 sports, training from age 6, competition from age 8 and a Young Athletes Programme for 2 to 7 year olds. Your local council can tell you about activities nearby.
Twice a week, 3 sets of 12, adding weight once 3 sets of 12 are possible, as in the trials. For the first 2 weeks, 1 or 2 sets while you learn each move (our editorial starting point).
3D demoLeg pressBeginner · Strength machine
3D demoLeg extensionBeginner · Strength machine
3D demoSeated calf raise (machine)Beginner · Strength machine
3D demoLat pulldownBeginner · A cable machine
3D demoChest press machineBeginner · Strength machine
3D demoSeated cable rowBeginner · A cable machine
3D demoDead bugBeginner · No equipment2 to 3 times a week. Start with sit-to-stands (15, holding on at first) and bridges (10, holding each for 5 seconds), as in a physiotherapy programme for adults with Down syndrome.
3D demoSit to stand from a chairBeginner · A bench or box
3D demoBodyweight squatBeginner · No equipment
3D demoGlute bridgeBeginner · No equipment
3D demoKnee push-upBeginner · No equipment
3D demoWall push-upBeginner · A wall
3D demoSide-lying leg raiseBeginner · No equipment
3D demoClamshellBeginner · No equipment
3D demoBand rowBeginner · A band + An anchor point
3D demoLow step-upBeginner · A step
3D demoSlow calf raiseBeginner · A wall
3D demoBird dog, one limb at a timeBeginner · No equipmentNext to a counter or rail, a few minutes most days: 3 holds of 10 seconds each side to start (our editorial starting point).
Use the talk test, not heart rate zones. Build towards 30-minute sessions (our editorial starting point).
Move gently through a comfortable range. Our suggestion: leave out headstands, shoulderstands, the plough and Pilates roll-overs unless a doctor has checked your neck.
Start with the gym routine from the trials twice a week, or the hypermobility strength and control routine at home. The chair workout suits adults who are less mobile.
The gym routine from the Down syndrome strength trials: 7 machine exercises for arms, legs and trunk, done with a buddy twice a week, and a balance finish.
40 minBeginner11 movesCardio machine, A cable machineA 25-minute low-load routine for hypermobile joints: hip, trunk and shoulder control plus balance, done slowly in the middle of your range.
25 minBeginner15 movesA bench or box, A wallFifteen minutes of animal moves, jumps and balance games for children, building the muscle- and bone-strengthening activity they need, with nothing to buy.
15 minBeginner16 movesA wallA 15-minute barefoot routine for stronger toes, arches, calves and ankles, finishing with balance. You need only a towel, a wall and a resistance band.
15 minBeginner11 movesA wall, Other / check instructionsA gentle 20-minute beginner home workout with a chair, a wall and a band: sit-to-stands, wall push-ups, band rows, step-ups and dead bugs.
20 minBeginner11 movesA bench or box, A wallBalance practice in 10 minutes: tandem stance, single-leg stands, marches, heel walks, tree pose and floor transfers.
10 minBeginner7 movesA wall, A bench or boxA 25-minute standing cardio circuit with no jumping: marching, step jacks, sit-to-stands, punches, step-ups and wall push-ups, with a seated option for most moves.
25 minBeginner9 movesA bench or box, A stepA steady 30 to 45 minute cardio session at talk-but-not-sing pace: walk, cycle, row or cross-train, counting toward weekly activity guidelines.
40 minBeginner3 movesCardio machine, A wallA 20-minute seated workout for older adults who cannot stand for long: marching, leg and arm strength, posture, and sit-to-stands that lead back to standing.
20 minBeginner11 movesA bench or box, Something with weightA weekly structure helps, especially with a buddy.
Your first four weeks: two, then three short strength sessions a week at home plus walks, building gently to a full routine.
2 training days20 minBeginner6 days a weekA free 8-week walking plan for beginners: build to 150 minutes of brisk walking a week, with intervals, hills and two short strength sessions.
6 training days40 minBeginnerIf any neck warning signs appear (see the neck section above). The Down's Syndrome Association says any parent, carer or coach with concerns "must refer the person for medical assessment". In adults, these changes can be wrongly put down to dementia.
For chest pain, dizziness or unusual breathlessness, and don't start again that day (our suggestion). Support: the Down's Syndrome Association helpline is 0333 1212 300.
Not without symptoms: the UK stopped recommending it in 1995 because X-rays don't predict who will have problems, and US guidance agrees for children and adults. In a trial, children with worrying X-rays who carried on with sport did no worse. Some sports bodies and Special Olympics programmes still ask for medical checks before particular events, so check the rules.
In strength and fitness trials there were no serious side effects. The UK guidelines say no evidence suggests appropriate activity is a risk for disabled adults, and the World Health Organization says there are "no major risks" when activity suits the person. What matters is knowing the neck and heart warning signs.
Machine training twice a week made adults, teenagers and young people stronger in randomised trials, with high attendance and no major side effects, and strength rose by a large amount across 16 trials.
Low muscle tone with loose ligaments means joints need stability, not more range. Physiotherapy focuses on strengthening the muscles around the joints, and flexibility work should be done with care.
The Down's Syndrome Association says it isn't. But exercise alone rarely shifts weight in young people with Down syndrome: food, sleep, thyroid checks and activity work together.
Maximum heart rate is lower in Down syndrome, so standard formulas set targets too high. Use the talk test.
A mix of strength training, activity that makes you breathe faster, and balance work, built around what you enjoy. Strength training has the strongest evidence: in trials, gym sessions twice a week made people stronger, with no serious side effects. Swimming, cycling and walking are good for muscles and joints, and dancing and sport count too.
The same as anyone: children an average of about an hour a day, and adults 150 minutes a week of moderate activity plus strength and balance work on at least 2 days. The UK guidelines for disabled children say 20 minutes a day brings good health benefits, built up slowly. The Down's Syndrome Association's easy-read advice is 1 hour a day for under-18s and 30 minutes, 5 days a week, for adults.
Yes, when it's supervised and built up gradually. Across 16 trials, strength training increased strength by a large amount and improved physical function, with no serious side effects. In the main trials, people trained on gym machines twice a week for 10 weeks, doing 3 sets of 12 and adding weight once 3 sets of 12 were possible.
Not if they have no symptoms. UK specialists stopped recommending routine neck X-rays in 1995 because they don't predict who will have problems, and US guidance agrees. Some sports bodies and Special Olympics programmes need medical clearance, and some still ask for X-rays before particular events, so check with your programme.
It means the top two bones of the neck move more than usual, because ligaments are looser in Down syndrome. It shows on X-rays in 10% to 27% of people but causes problems in very few. Stop sport and see a doctor for neck pain, a stiff neck that doesn't settle, a tilted head, changes in walking, clumsier hands, or new bladder or bowel problems; get an urgent appointment if they come on suddenly.
UK and US advice differ in strength. The UK's Down's Syndrome Association says trampolining, diving, contact sports and high jump carry a higher neck-injury risk for everyone, with no evidence of extra risk from a mini-trampoline for a child without symptoms. The American Academy of Pediatrics advises all children to avoid trampolines unless in a supervised programme, and says contact sports carry a risk of spinal cord injury. With any neck symptoms, stop sport until a doctor has checked you.
Usually yes, but ask your heart team what level of activity is safe for you. About half of babies with Down syndrome have a heart condition, and teenagers and adults should have their heart checked regularly, because valve problems can appear later. See a doctor for breathing difficulties, unusual tiredness, dizziness or chest pain, and call 999 if someone faints during exercise.
People with Down syndrome have a lower maximum heart rate, probably because of differences in the nerves that control the heart. That means heart rate zones from age-based formulas aim too high. Use the talk test instead: if you can talk but not sing, you're working at a moderate effort.
It helps fitness, strength and health, but exercise programmes on their own haven't reliably reduced weight in young people with Down syndrome. A lower resting metabolic rate, thyroid problems and sleep apnoea all play a part, so food, sleep and health checks matter too. The Down's Syndrome Association suggests tracking small wins rather than focusing on the scales.
Yes: the usual advice is to strengthen the core and the muscles that steady the joints, the same strength-and-control-first approach as our hypermobility guide. Build up slowly, do flexibility work with care, and favour a comfortable range over deep stretches. Insoles can help if flat feet hurt.
Yes. Special Olympics is open to anyone with an intellectual (learning) disability, not only people with Down syndrome, and it asks for a medical examination of all athletes. Rules about the neck vary: Special Olympics Ireland, for example, restricts events such as butterfly stroke, diving starts, high jump and football until a doctor has checked the neck. Ask your local programme what they need.
The Down's Syndrome Association's DSActive programme supports people to join sessions from local clubs to international sport, and DSEngage runs free online sessions. Special Olympics GB offers 27 sports, competition from age 8 and a Young Athletes Programme for 2 to 7 year olds. Your local council can tell you about activities nearby.
Exercise education, not a diagnosis or treatment plan, and clinical review of these guides is pending. Stop and get advice for chest pain, unusual breathlessness, dizziness or fainting, or new pain, and check with your doctor or midwife first if they have told you to limit activity. Health disclaimer.
