Balance and Down Syndrome

February 2025 | Jennifer Spiric, PT, DPT and Brian Chicoine, MD - Mann Method PT and Fitness and Adult Down Syndrome Center

Key Points

Differences in the body's sensory systems in people with Down syndrome can contribute to impairments in balance.
Impaired balance can limit the ability or willingness of people with Down syndrome to participate in activities.
There are exercises that can improve balance and stability.

Overview

People with Down syndrome can experience difficulties with balance. This can affect their walking (gait) and may be paired with:

Decreased participation in or independence with activities that require balance,
Differences in steadiness while walking on different types of surfaces (e.g., sand, snow, hiking trails, etc.),
Fear of or resistance to participating in tasks and movements that challenge balance, and/or
Reports of dizziness or unsteadiness when balance is challenged during a movement or activity.

Our bodies have several sensory systems that contribute to our sense of balance. People with Down syndrome often have differences in each of these sensory systems compared to people without Down syndrome. These differences can directly affect their balance. Fortunately, much like there are exercises that improve muscles strength and cardiovascular endurance, there are also exercises that improve balance and stability.

In this article, we will discuss balance systems, the differences in the balance systems of people with Down syndrome, and strategies for supporting adults with Down syndrome to promote improved balance and stability for increased confidence and independence at home and in the community.

What body systems affect balance?

Vision

Our eyes give our brain visual information about the environment around us and our position relative to the environment. Our two eyes work together to understand how we are moving relative to the world around us and give us depth perception information to understand how far away things are from our hands or feet. By adulthood, approximately 50-75% of people with Down syndrome have a change in their visual system that could impact balance (1-2).

Vestibular

A complex system inside our inner ears gives our brain information about how our head is moving through space in different planes of motion – side to side, forward and backward, and with rotation. The vestibular system can be over-sensitive or under-sensitive in each of the planes of motion. This can cause difficulty sensing changes in head position or eliciting balance reactions in one direction of movement, while another plane of movement can cause a big feeling of unsteadiness, dizziness, or discomfort.

Changes in hearing and hearing impairment have also been closely linked with changes in balance (3). Interestingly, what we hear (auditory information) and the sensation of our head’s movement through space (vestibular information) travel on the same nerve to the brain and seem to be closely related. By adulthood, approximately 50-75% of people with Down syndrome have a change to their inner ear systems that could impact balance (4-6).

Proprioception

Specialized receptors in our muscles and joints give our brain information about where our body is in space. These receptors send fewer signals when muscle tone is low or when ligament structures have increased flexibility. Nearly all people with Down syndrome have low muscle tone and ligamentous laxity that could impact balance and balance reactions (7).

What medical conditions can affect balance?

Vision

Cataracts (clouding of the cornea)
Visual impairment (visual acuity, need for glasses)
Strabismus (crossing of the eyes or "lazy" eye)
Nystagmus (rapid eye movements)
Cerebral visual impairment (vision impairment occurring in the brain rather than in the eyes)

Hearing and vestibular

Ear infections
Chronic sinus and nasal congestion that cause increased inner ear fluid
Cerumen impaction (ear wax buildup)
Hearing impairment

Proprioception

Ligamentous laxity
Hypotonia (low resting muscle tone)
Bed rest or surgery recovery

Other

There are other factors to consider when a person's walking (gait) changes. More information is available in this Changes in Gait article.

What can we do to improve balance?

Just like there are exercises to improve strength, joint stability, and cardiovascular function, there are also exercises that can help improve balance (8-14). When starting exercises to improve balance, participants should practice in positions that are safe. You can improve balance even in a sitting position and progress to standing.

Exercises that improve balance include shifting your weight from side to side and front to back. Some exercises require visual vestibular coordination. This means that you practice moving your head and neck (activating your vestibular system) while also using your eyes to focus on specific targets. This combination of movements helps your visual and vestibular systems work together more effectively for balance. There are examples of these types of exercises provided below.

These balance exercises are done in the different planes of motion – rotating side to side (the transverse plane), up and down or forward and backward (the sagittal plane), and left and right (the frontal plane). They can be practiced on different surfaces and with different levels of support (standing on one foot, holding on to the counter, or even practicing balance as part of aqua therapy).

Here are some of the balance exercises developed by Dr. Spiric that are included as part of the balance and visual vestibular elements of the Mann Method PT program (8).

Side to side weight shifts

Stand with your feet a little wider than hip width apart.
Place arms out to the side for balance (improves shoulder strength and body awareness).
Shift weight from one foot to the other, gently lifting the opposite leg off the floor.
Try 10 in a row.
Notes and tips:
- Keep legs straight.
- Move slow and controlled.
- Keep toes pointed forward and gaze looking forward.
- You can use a mirror, picture, colored dot, or partner to practice looking forward as you move.
- Stand with hands supported from behind by a wall, from in front on a countertop, or by a caregiver. Progress to independent weight shifts and balance when ready.

Forward and backward weight shifts

Stand with one foot a little in front of the other one, feet spaced about hip width apart.
Point your toes forward as much as you can. Put your hands on your hips.
Shift weight from one foot to the other, gently lifting the opposite leg off the floor.
Try 10 in a row. Then switch your forward foot and do 10 more!
Notes and tips:
- Keep legs straight.
- Move slow and controlled.
- Keep toes pointed forward and gaze looking forward.
- You can use a mirror, picture, colored dot, or partner to practice looking forward as you move.
- Start with on hand on a wall, chair, or countertop or supported by a caregiver. Progress to independent weight shifts with hands on hips for a balance challenge when ready.

Standing marches

Stand with your feet hip width apart.
Hold a lightweight ball at belly button height using both hands OR place your hands on a wall, countertop, or caregiver's shoulders for balance support.
March your RIGHT knee to touch the ball.
Put your foot down.
March your LEFT knee to touch the ball.
Put your foot down.
Keep marching by alternating RIGHT and LEFT knee each time.
Try 20 total - 10 for each leg.
Notes and tips:
- Keep your eyes looking at the ball as you march.
- Move slow and controlled.

Rotational ball passes or taps

Sit or stand back-to-back with a partner OR sit or stand with your back to a wall.
- If you sit or stand with your back to a wall, put a decal/sticker/chalk dot on the wall at shoulder height.
Hold a lightweight ball with both hands.
Turn to the RIGHT, see the target (partner's hands OR decal/sticker/chalk mark) and pass the ball to the target.
Now turn to the LEFT, see the target, and receive the ball from your partner OR tap the ball to the decal/sticker/chalk dot on the wall.
Repeat 10 times in a row.
Notes and tips:
- Go slow and take the time to see the target first before passing or tapping the ball.
- Twist your upper body and try to keep your feet or legs still.
- If you feel a little dizzy, place your hands on top of your head and take a few big breaths.
- If you feel too dizzy, sit down or try this activity slower or seated at first.

Tips for better balance

Make it a routine. You can do the balance exercises every day. The recommended amount is at least 3 times per week.
Use visual cues for where to stand the feet, what to hold on to with the hands, and where to look with the eyes for each exercise. Visual cues help with body awareness, independence, accuracy, and coordination.
Provide hand support on a wall, back of a chair, handle, countertop, or another person’s hand as needed to build confidence and promote safety and stability during these exercises.
Make movement a daily routine (e.g., walking, dancing, swimming, exercising, etc.) to encourage ongoing coordination of the balance systems and continued strengthening or muscles throughout the body that help with balance and stability.
Wear supportive shoes because when your feet feel steady your balance feels better, too!