Pilates guide
Pilates can be a good way for children and adults with Down syndrome (also called Down's syndrome) to build trunk control, balance and strength, alongside strength training, sport and the usual health checks. In the one published trial, 40 children aged 8 to 10 who swapped half of their physiotherapy session for Pilates, 3 times a week for 12 weeks, gained more balance and coordination than children who had physiotherapy alone. It was small, in one clinic, nobody was followed up afterwards, and it may overstate the effect. No Pilates trial has included adults.
Because muscle tone is lower and ligaments are looser, the aim is stronger muscles and better control, not more stretching, and a few classical moves that put weight through the head and neck are best left out. Down syndrome is a genetic condition, not something Pilates treats.
This guide covers what the evidence shows, strength before stretch, the neck warning signs, the heart and the talk test, teaching a class, and a free 25-minute class to do with a buddy.
"Down's syndrome is when you're born with an extra chromosome." (the Down's Syndrome Association) Pilates can help children and adults build trunk control, balance and strength around loose joints, alongside strength training, sport and the usual health checks.
In Egypt, 40 children aged 8 to 10 had physiotherapy 3 times a week for 12 weeks, either a 90-minute session or 45 minutes of it plus 45 minutes of Pilates; the Pilates group gained more in balance, coordination and quality of life scores. It was small and short, its registry record came after it started and planned a different number of children, and its data are unusually tidy. No Pilates trial has included adults.
Across 16 trials, resistance training increased strength by a large amount, and "There were no serious adverse effects." Pilates fits beside it, not instead of it; our exercise for Down syndrome guide has the strength plan.
Low muscle tone and loose ligaments lead "to excessive flexibility in the joints", and "Physiotherapy can help to strengthen the muscles around the joints and can improve stability and coordination." Keep every move in the middle of its range.
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Leave out roll-overs, jack knives and other legs-overhead moves (our suggestion, from the neck guidance). Without symptoms, routine neck X-rays aren't recommended, and the Down's Syndrome Association says "there should be no additional anxiety about them taking part in non-contact, low impact sporting activities". Stop and see a doctor if a neck warning sign appears.
"About half of all children who have Down's syndrome are born with a heart condition", so ask the heart team what is safe. Maximum heart rate is lower in Down syndrome, so the usual heart rate zones aim too high: if you can talk but not sing, the effort is moderate.
The Down's Syndrome Association: "People who have Down's syndrome will have some level of learning disability." It says both "Down's syndrome" and "Down syndrome" can be used, and asks for person-first words: a person who has Down syndrome. Our exercise for Down syndrome guide covers how common it is.
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The Down's Syndrome Association says muscle and joint problems are "mainly due to low muscle tone (hypotonia) and loose ligaments (ligament laxity), leading to excessive flexibility in the joints", and that joint hypermobility "can make it harder for children and adults to stabilise their joints and maintain a good posture". In 503 Irish children with Down syndrome, joint laxity was almost universal and flat feet affected 91%.
Work capacity and peak fitness are lower on average, along with a lower maximum heart rate. A physiotherapy programme for adults estimates maximum heart rate with a formula made for Down syndrome, 179 minus 0.56 times age, rather than the usual one.
"Underlying neck instability is more common in people who have Down's syndrome than in the general population." (the Down's Syndrome Association) The UK's Down Syndrome Medical Interest Group (DSMIG) says in its 2024 guidance that as many as a third of children have extra movement at the top of the neck, mostly without symptoms, and that instability causing symptoms affects about 2%; the American Academy of Pediatrics (AAP) gives 1% to 2%.
"About half of all children who have Down's syndrome are born with a heart condition." Heart conditions "can also occur later in life", and everyone with Down syndrome aged 14 and over is entitled to a free Annual Health Check with their GP.
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In children, the AAP lists hearing loss (75%), vision problems (60% to 80%), thyroid disease and autism among common conditions. A physiotherapy programme for adults describes people with Down syndrome as often "Excellent visual learners", and notes that pain may show late.
Many classes reward flexibility (the spine stretch forward, the saw, splits); curl-ups lift the head; roll-overs and jack knives put body weight on the neck; planks load wrists and elbows that may bend back too far; standing balance work is where the trial found gains; and quick spoken cues in a group suit few people (our list).
Children with Down syndrome are often less active than the guidelines suggest, and in a European survey, "caregivers who exercised regularly had up to thirteen-fold higher odds of having a physically active family member with DS". The Down's Syndrome Association's free online sessions include Pilates: "From dance and discos to a workout and a Pilates session, there is something to suit everyone."
Strength training carries the best evidence in Down syndrome. Pilates has one small trial, in children.
In a Cairo clinic, 40 children aged 8 to 10 were randomised to 90 minutes of physiotherapy, or 45 minutes of it plus 45 minutes of Pilates, 3 times a week for 12 weeks. The Pilates block was a bridge, the Hundred, toe taps, leg circles, side kicks, arm and leg raises on all fours, a kneeling twist, standing side leg raises, heel-to-toe walking and a wall squat, done "slowly and smoothly". The Pilates group ended with better balance, coordination and quality of life scores than the physiotherapy-only group.
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The authors note "A small sample size and a specific age range were included." and "Also, the children's follow-up was not documented." The paper doesn't report side effects or any neck checks, although its Hundred lifts the head. Its registry record was submitted about 5 months after the start date the paper gives, and planned 30 children with no quality of life measure. Its spreads of results are very small and its effect very large, tidier than real data usually are. Two newer reviews rate it fair quality.
Our searches on 2 November 2026 found only that trial. A 22-child trial in Pakistan finished in 2023 with no results posted, a third trial is recruiting, and a 2009 report described 4 young people with no comparison group. No Pilates trial has included adults with Down syndrome.
Across 8 trials (260 children, all from 4 countries), balance exercise improved dynamic balance, and a review of 11 studies says the findings must be read with caution because of a high risk of bias. Core stability work added to physiotherapy improved balance in 45 children aged 4 to 6 in one trial.
Across 16 trials, resistance training increased strength by a large amount and improved physical function, and "There were no serious adverse effects." A 2026 review of 8 trials in 266 teenagers and young adults found a moderate effect, larger in the legs. Walking and stair climbing didn't clearly change. In an Australian trial, 68 young people trained on machines twice a week with a student buddy and attended 92% of their sessions.
Exercise programmes raised peak fitness across 10 trials, and "No adverse effects were reported in any of the studies." The only Cochrane review, from 2010, found too little evidence in adults. Body weight fell only slightly across 13 trials, so Pilates isn't a weight-loss plan.
Combined exercise raised upper and lower body strength in adults, with low to moderate certainty. A 12-month trial in 81 adults found remote group exercise 3 times a week workable, though it didn't change memory or overall thinking scores, and adults in it who had a heart condition had no more side effects than the others.
International experts met in 2025 to plan fitness guidelines for people with Down syndrome; none had been published by November 2026.
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With low muscle tone and loose ligaments, joints need stability, not more range. Physiotherapy builds strength around the joints, and flexibility work needs care. In Pilates, that means slow, controlled moves held in the middle of the range.
Keep knees and elbows soft, stop short of the end of each movement, and choose control over height or depth. Supportive shoes or a non-slip mat help flat feet (our suggestion; our Pilates for flat feet guide has more).
In the strength trials, a student buddy trained alongside each young person, and attendance was 90% or more. Families where the carers exercise tend to be more active too. Our class is written for two.
Pilates 2 or 3 times a week as part of the week's strength and balance work, beside 2 strength sessions and walking, swimming or sport for adults, and active play for children (our editorial starting point, from the trial's 3 sessions a week, the strength trials' 2 and the UK guidelines' strength and balance activities on at least 2 days a week). The UK guidelines for disabled adults add: "Even a little movement is better than nothing."
The trial's gains were in balance and coordination, and core stability training also helped balance in young children. Our class keeps the trial's standing balance moves, beside a counter or wall.
Loose ligaments can let the top two bones of the neck move more than usual. DSMIG's 2024 guidance: "The incidence of clinically significant/symptomatic atlantoaxial instability is approximately 2%." About 1% need an operation.
DSMIG: "routine radiological screening for asymptomatic people with Down syndrome is not recommended by DSMIG, the American Academy of Paediatrics and others", and people without symptoms "should not be barred from normal sporting activities". The US guideline for adults says the same for adults.
DSMIG's 2024 guidance says the Special Olympics "no longer requires radiographic screening of athletes with Down syndrome". But Special Olympics Ireland's 2023 rules still ask for a doctor's examination, including neck X-rays, before some events. The rules differ between programmes, so check with yours.
Stop sport and see a doctor if any of these appear; get an urgent appointment if they come on suddenly (our neck pain in children guide covers the other causes of a child's neck pain):
DSMIG's 2024 guidance says the signs "may overlap with other pathologies seen in Down syndrome, such as feeding problems, obstructive sleep apnoea or Alzheimer disease in adulthood". In adults, new clumsiness or unsteady walking can be the neck, not dementia, so get it checked. The Down's Syndrome Association: "If symptoms come on suddenly, an urgent appointment is needed."
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.
In Pilates, we suggest leaving out the jack knife, control balance, boomerang, crab and high scissors and bicycle too, on the same reasoning.
Keep the head down in the Hundred and other curl moves, and never pull on the head. The trial lifted the head; keeping it down is our suggestion, and no study has looked at curl-ups and neck instability. With any neck warning sign, stop Pilates and see a doctor first.
About half of children with Down syndrome are born with a heart condition, and problems can appear later in life. With a heart condition, past heart surgery or high blood pressure in the lungs, ask the heart team what level of activity is safe before starting.
Maximum heart rate is lower in Down syndrome, so the usual heart rate zones aim too high. If you can talk but not sing, you're working at a moderate effort.
Holding the breath raised blood pressure during practice in a lab study of 20 healthy adults. Pilates breathing doesn't need holds; with a heart condition, leave them out (our suggestion).
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In a supervised exercise trial, 36 adults with Down syndrome and congenital heart disease had no more side effects than those without. The summary we read doesn't say which heart conditions they had.
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Everyone with Down syndrome aged 14 and over is entitled to a free Annual Health Check with their GP. Children's heart, thyroid, sight and hearing checks carry on alongside any exercise.
Many people with Down syndrome are "Excellent visual learners". Show each move, or use the 3D figure, do it alongside, and check each move is done well before making it harder.
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Hearing and vision problems are common, so face the person, keep instructions short and give one at a time (our suggestion).
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Keep the order fixed, count out loud together, and use the same words for each move each time (our suggestion).
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For young children, the physiotherapist leads: the NHS lists "a physiotherapist for help walking, if your child has low muscle tone". Keep it playful and short. Without neck warning signs, children can join ordinary classes; leave out legs-overhead and rolling moves (our suggestion).
New clumsiness or unsteady walking can be the neck rather than dementia, so get it checked. A chair-based class in the same order (our chair Pilates for dementia class) suits adults who are less steady on their feet.
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Some people with Down syndrome show pain late or in other ways, so watch for limping, guarding a limb or a change in mood, and stop to check (our suggestion, from a physiotherapy programme for adults).
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A reformer's springs and moving carriage need close one-to-one teaching from someone who knows loose joints and the neck. Mat Pilates is the only kind tested in Down syndrome (our suggestion).
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Lateral breathing: 5 to 8 breaths at the start of every session (from the move page's dose), with no holding the breath; breath reach: "5 breaths, exhale longer than inhale" (the move page's dose); corpse pose: 2 to 3 minutes with a folded blanket under the head, sitting up at any time (our yoga for Down syndrome class gives 3 minutes; shorter than the move page's dose).
Glute bridge: 10, holding each for 5 seconds (the physiotherapy programme for adults with Down syndrome, as our exercise guide gives it); dead bug heel taps: 5 to 10 each side (our cerebral palsy Pilates class); single-leg circle: 5 small circles each way, each leg, the other knee bent (adapted from the move page's dose); the Hundred: 30 to 50 beats, head down and knees bent (our cerebral palsy class; head down is our suggestion).
Side kick: 6 to 8 each side, bottom knee bent, small swings (our cerebral palsy class); clamshell: 8 each side (our hypermobility class); bird dog, one limb at a time: 5 each arm and leg with a 3-second hold, reaching long, not high (our yoga for Down syndrome class); thoracic rotation: "6 rotations per side, moving with the breath" (the move page's dose), sitting on a chair.
Sit to stand: 10, holding on at first, and wall push-up: 8 slow, elbows soft (our yoga for Down syndrome class); sit squat: 5 to 8 shallow, back near a wall (our cerebral palsy class); wall side leg lift: 8 each side and heel-to-toe walk: hold 10 seconds each way, then 5 steps heel to toe, twice (our standing Pilates for balance class); single-leg and semi-tandem stands: 3 holds of 10 seconds each side, next to a counter (our exercise for Down syndrome guide's editorial starting point).
3D demoSit to stand from a chairBeginner · A bench or box
3D demoWall push-upBeginner · A wall
3D demoSit squat (partial squat)Beginner · No equipment
3D demoWall side leg lift (standing side kick at the wall)Beginner · A wall
3D demoTandem stance and heel-to-toe walkBeginner · A wall
3D demoSingle-leg standBeginner · A wall
3D demoSemi-tandem stanceBeginner · A wallEach change is our suggestion, from the sources named; none has been tested in a trial.
The roll-over, jack knife, control balance, boomerang, high scissors, high bicycle and the crab: leave them out. Our exercise for Down syndrome guide already says this of roll-overs; the others are ours, on the same reasoning.
They roll onto the shoulder blades, not the neck, and the Down's Syndrome Association says there's no evidence that forward rolls carry more risk for a child without symptoms. They add little that a bridge and the Hundred don't, so our class leaves them out, and never do them with a warning sign.
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The chest lift, single-leg stretch, criss-cross, the Hundred with the head up and the neck pull: head down, or hands behind the head without pulling. Stop and see a doctor if any neck warning sign appears.
The saw, the spine stretch forward, splits and long holds at the end of a joint's range: leave them out or keep them small.
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The leg pull front, knee hover and push-up: elbows soft, and fists or forearms for the wrists, as the moves' hypermobility cautions say. Start with the wall push-up.
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None in this class, and leave them out with a heart condition.
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Our Pilates class with a buddy is new and untested: it's built from the moves in the one Pilates trial in children with Down syndrome, with the head down throughout and nothing that loads the neck. The strength workout follows the strength trials and has the best evidence; the yoga class is done with a buddy too; the hypermobility class suits teenagers and adults (do its chest lift with the head down); the cerebral palsy class uses similar moves; the balance class suits people who walk steadily; and chair Pilates suits people who are less mobile.
A 25-minute Pilates class for children and adults with Down syndrome, done with a buddy: trunk control, balance and strength, with nothing on the head or neck.
25 minBeginner15 movesBench or box, wallThe 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, cable machineA 20-minute yoga class for children and adults with Down syndrome, done with a buddy: strength, balance at a wall, gentle movement and rest, nothing on the neck.
20 minBeginner14 movesBench or box, wallA 20-minute Pilates class for hypermobile joints, HSD and hEDS: supported positions first, mid-range control, slow changes and steady breathing.
20 minBeginner17 movesOther / check instructions, bandA 25-minute adapted Pilates class for children and adults with cerebral palsy: lying, sitting and standing with a chair, with a seated option for each block.
25 minBeginner16 movesBench or box, wallA 25-minute Pilates class for steadier balance: standing balance and leg strength at a kitchen counter, then mat work for your trunk and hips.
25 minBeginner17 movesWall, bench or boxA 20-minute chair Pilates workout for beginners and older adults: breathing, sitting tall, gentle spine and leg moves, and a standing finish at the chair.
20 minBeginner14 movesBench or box, something with weightThis is general information, not a diagnosis. A&E means accident and emergency; in the US, call 911 for 999, and use your doctor's urgent line or urgent care for NHS 111.
If 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.
The Down's Syndrome Association's helpline is open Monday to Friday, 10am to 4pm.
You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.
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The NHS's advice:
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Down syndrome is a genetic condition. Pilates, like other exercise, can build strength and control around loose joints, but no study shows it changes muscle tone itself.
The flexibility comes from low muscle tone and loose ligaments, which make joints harder to stabilise. The aim is strength and control in the middle of the range.
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Without symptoms, the Down's Syndrome Association says people "should be encouraged to take part in recreational exercise and sporting activities for the same benefits as anyone else in the population." Everyday neck movement is fine; what's left out is putting body weight through the head and neck, and anything at all once a warning sign appears.
Not without symptoms: UK and US guidance advises against routine X-rays, because they don't predict who will have problems. Some sports bodies, such as Special Olympics Ireland, have their own rules for some events; ask them.
Strength trials reported no serious side effects, the UK guidelines found no evidence that appropriate activity is a risk for disabled adults, and adults with a heart condition in a supervised trial had no more side effects than others. Know the neck and heart signs.
Machine training twice a week made teenagers and young people stronger in randomised trials, with 90% or more of sessions attended. Pilates is a complement to strength training, not a replacement.
Maximum heart rate is lower in Down syndrome, so age-based zones aim too high. Use the talk test.
The one trial used mat, ball and wall work, and the NHS's own Pilates videos are mat and chair classes. A reformer needs a teacher who knows loose joints and the neck (our suggestion).
It can be a good way to build trunk control, balance and strength. In the one trial, 40 children aged 8 to 10 who did Pilates as part of their physiotherapy gained more balance and coordination than children who had physiotherapy alone, though the trial was small and may overstate the effect. Strength training has the most evidence, and Pilates fits alongside it.
Yes, with their care team's agreement. Keep it playful and short, show each move, use the same order each time, and leave out moves that put weight on the head or neck. Children without neck warning signs can join ordinary classes.
It can help strength and balance, though no Pilates trial has included adults. Exercise builds strength in adults with Down syndrome, and a year of remote group exercise 3 times a week worked well for adults in a 2026 trial. The Down's Syndrome Association's free online sessions include Pilates.
It can help build strength and control around the joints, which is what physiotherapy for Down syndrome aims at. It doesn't change muscle tone itself, so hold moves in the middle of the range rather than stretching further.
The moves from the trial: bridges, heel taps lying on your back, small leg circles, side kicks, arm and leg reaches on all fours, a seated twist, standing side leg lifts, heel-to-toe walking and a shallow wall squat, plus sit-to-stands and wall push-ups. Our 25-minute class puts them in order.
Roll-overs, jack knives and other moves that take the legs overhead and put weight on the neck, deep end-of-range stretches, and any move once a warning sign appears. Keeping the head down in curl moves is our suggestion too.
Not if they have no symptoms: UK and US guidance doesn't recommend routine neck X-rays, because they don't predict who will have problems. Some sports programmes have their own rules for some events. With any warning sign, stop and see a doctor first.
Neck pain or a stiff neck that doesn't settle, an unusual head position, a change in walking or tiring more easily, clumsier hands, trouble holding the head up, weakness, new bladder or bowel problems, frequent falls, or new breathing, sleep apnoea or swallowing problems. Stop sport and see a doctor; if they come on suddenly, get an urgent appointment.
Usually, but ask the heart team what level of activity is safe first. About half of children with Down syndrome are born with a heart condition, and problems can appear later, so keep up heart checks. Leave out breath holds, and use the talk test.
It hasn't been tested. A reformer's springs and moving carriage need close one-to-one teaching, movement in the middle of the range and no moves that load the neck; mat Pilates is the tested option (our suggestion).
Two or three times a week is a good start; the trial ran 3 sessions a week for 12 weeks. Add strength training twice a week for teenagers and adults, and plenty of active play for children.
Show each move or use the 3D figure, face the person, give one short instruction at a time, keep the same order, and do it together with a buddy. Check each move is done well before making it harder.
Exercise education, not a personal prescription, and clinical review of these guides is pending. If you are pregnant, have a health condition or have had recent surgery, check with a doctor, midwife or physiotherapist before starting, and stop for sharp or increasing pain. Health disclaimer.
