R E S E A R C H R E P O R T

Effects of Aerobic Conditioning

and Strength Training on a
Child with Down Syndrome:
A Case Study
Cynthia L. Lewis, PhD, PT, and Maria A. Fragala-Pinkham, MS, PT
Department of Physical Therapy Education (C.L.L.), Elon University, Elon, NC; Research Center for Children with
Special Health Care Needs, Franciscan Hospital for Children and Boston University, Health and Disability Research
Institute (M.A.F.), Boston, MA

Purpose: To determine the effects of a home exercise program of combined aerobic and strength training on
fitness with a 10.5-year-old girl with Down syndrome (DS). Measurements included cardiovascular variables,
strength, body composition, flexibility, and skill. Methods: The subject participated in a home exercise pro-
gram: 30 to 60 minutes of moderate- to high-intensity exercise five to six days per week for six weeks. The
cardiovascular variables monitored were heart rate, respiration rate, and oxygen consumption during a
submaximal treadmill stress test. Other measures included 10-repetition maximal strength of selected muscle
groups, body mass index, flexibility, Gross Motor Scales of the Bruininks-Oseretsky Test of Motor Proficiency,
and anaerobic muscle power. Results: Improvements in submaximal heart and respiration rates, aerobic
performance, muscle strength and endurance, gross motor skills, and anaerobic power were observed for this
subject. Body weight and flexibility were unchanged. Conclusions: For this subject, a combined aerobic and
strength-training program resulted in improved cardiopulmonary functions not observed in previous studies
of subjects with DS. (Pediatr Phys Ther 2005;17:30 –36) Key words: child, cardiovascular system/physiopathol-
ogy, case study, Down syndrome, exercise test, oxygen consumption, physical fitness, physical therapy/
methods

INTRODUCTION impair upper extremity midline movements and gait, noted

Down syndrome (DS) was the first genetic disorder
attributed to a chromosomal abnormality (trisomy 21) and
is the most common genetic form of mental retardation.1
The syndrome is characterized by several clinical symptoms
that often include orthopedic, cardiovascular, neurological,
cognitive, hormonal, and visual perceptual impairments.
Individuals with this disorder have hypotonia and
ligamentus laxity, which contribute to orthopedic impair-
ments. Hypotonia and muscle weakness are theorized to
0898-5669/05/1701-0030
Pediatric Physical Therapy
Copyright © 2005 Lippincott Williams & Wilkins, Inc.
Address correspondence to: Maria A. Fragala-Pinkham, PT, Research
Center, Franciscan Hospital for Children, 30 Warren Street, Brighton,
MA 02135. Email: mfragala@fchrc.org
DOI: 10.1097/01.PEP.0000154185.55735.A0
by shorter step lengths, increased knee flexion at foot con-
tact, decreased single-limb support, and increased hip flex-
ion posture that can contribute to the higher energy cost of
gait in persons with this disorder.2 Children with DS have
decreased pulmonary function and physical fitness com-
pared with peers who are typically developing.3
Obesity is common in postpubescent males and fe-
males with DS. They have a shorter stature and a higher
percentage of body fat, and a greater body mass index than
age-matched peers.4 Despite comorbidities, life expectancy
for individuals with DS has significantly increased over the
past three decades. More than 80% of individuals with DS
survive past 30 years of age.1 However, with this increased
life expectancy come other secondary disorders, including
increased incidences of diabetes mellitus and Alzheimer-
like dementia after age 30 or 35 years.5,6 Individuals with
DS are more sedentary than their siblings.7,8 Higher inci-
dences of diabetes and obesity and a sedentary lifestyle are
primary risk factors for cardiovascular disease.9,10

30 Lewis and Fragala-Pinkham Pediatric Physical Therapy

 Researchers have demonstrated the beneficial effects
of aerobic conditioning in preventing, delaying the onset,
and the management of cardiovascular disease, diabetes,
and obesity in populations without DS.9 Aerobic condi-
tioning may also help reduce these risk factors in the pop-
ulation with DS. However, although many characteristics
of DS are documented, less well understood are the effects
that these characteristics have on exercise performance and
aerobic training.
At submaximal workloads, individuals with DS have
higher heart rates (HRs), oxygen consumption (VO2), and
minute ventilation (VE) than peers with mental retardation
but without DS and peers without impairment.10 However,
at maximal effort, individuals with DS have lower mean
peak HRs and lower VO2, suggesting a lower level of aerobic
conditioning.11–13 Individuals with DS were found to have
two thirds the mean force in hip abductor strength and half
the mean force in knee extensor strength when compared
with peers with mental retardation but without DS.14 Sub-
jects with DS had a high correlation (r ⫽ 0.84) between
lower limb strength and oxygen consumption during max-
imal treadmill stress testing that is not observed in individ-
uals without impairment.15 Thus, skeletal and respiratory
muscle weakness may be contributing factors to lower
maximal oxygen consumption observed in individuals
with DS during treadmill stress testing. Although a tread-
mill stress test is designed to examine the maximal perfor-
mance of the cardiovascular system rather than the skeletal
muscle system, in persons with DS, muscular fatigue may
occur before the cardiovascular system is maximally
stressed.
Individuals with DS may benefit from aerobic condi-
tioning, but the program’s frequency, intensity, and dura-
tion need to be modified from the general recommenda-
tions of the American College of Sports Medicine (ACSM).9
Researchers have demonstrated the improvements in car-
diovascular function in sedentary individuals without im-
pairment who participated in aerobic training for 30 min-
utes at 65% to 75% maximal VO2 three times per week.9
Cardiovascular benefits with aerobic conditioning include
a lower resting HR, lower submaximal HR, respiration
rates (RRs), and VO2, and higher VO2 at maximal
workload.16,17
When persons with DS participated in aerobic train-
ing programs following the ACSM guidelines, they im-
proved their endurance but showed no changes in cardio-
vascular function.18,19 Miller et al18 conducted a 10-week
jogging program and Varela et al19 carried out a 16-week
upper body ergometry-rowing program with young adults
with DS. Subjects participated in aerobic activity 30 min-
utes at 65% to 75% VO2 maximum three times per week.
Following aerobic training protocols, subjects with DS in-
creased their aerobic endurance but showed no changes in
cardiovascular variables such as resting HR or submaximal
HR, VO2, and VE. Subjects, however, walked longer on the
treadmill or rowed longer on the upper body ergometer,
indicating increased aerobic performance.
Aerobic conditioning programs produced improve-
Pediatric Physical Therapy
ments in endurance but not in cardiovascular function in
subjects with DS. The high correlation of strength to VO2
during treadmill stress testing would suggest that a com-
bined strength training and aerobic conditioning program
may be more effective for enhancing cardiovascular func-
tion in individuals with DS than aerobic training alone.
Muscle weakness and muscle fatigue may be limiting fac-
tors in aerobic training programs in subjects with DS that
are not observed in subjects without impairment.
The purpose of this single case study was to investi-
gate the effects of a six-week home treatment program for a
10.5-year-old girl with DS. The program combined aerobic
conditioning and strength training for 30 to 60 minutes
daily at 70% to 80% intensity six days per week.
METHODS
Subject
The subject was a 10.5-year-old girl with DS. As a
third grade student, she received consultative physical
therapy services once monthly through the school system.
She participated one hour per week in sport skills activities
through the Special Olympics Organization that included
swimming, basketball, and soccer. She had cognitive im-
pairments but was able to follow two-step commands. Her
parents’ concerns were that she was overweight and fa-
tigued easily. She was unable to keep up with her siblings
on family outings. The parents’ goals for the program were
increased functional endurance and weight loss. The sub-
ject’s interests were music and dancing.
As an infant, she had surgery to repair a ventriculosep-
tal defect, and, according to the cardiology consultation
report, she did not have any residual cardiac problems. At
the time of the study, she had no medical problems and was
on no medication. Physician approval and parental consent
were received for the subject to participate in a home ex-
ercise program.
Design
The study was a single case study design. Assessments
were done before and after intervention. Her program con-
sisted of a physical therapy consultation to monitor
progress and update the program once per week and a daily
home exercise program for six weeks. Her home exercise
program took place initially four to five days per week
increasing to six days per week. By the third week, she
performed aerobic activities three days per week alternat-
ing with strength training three days per week. She contin-
ued to receive once-monthly physical therapy consultation
with the school system for academic-related concerns.
Testing
The subject was assessed in the following areas: car-
diovascular function, body dimensions, flexibility, gross
motor skills, anaerobic power test, and muscle strength
and endurance.
Conditioning and Strengthening in Down Syndrome 31
 Cardiovascular Testing. Oxygen consumption was
measured to assess aerobic performance during a submaxi-
mal treadmill stress test following the protocol of Rose et
al.20 The subject had one practice session on the treadmill
one week before testing to familiarize her with walking on
a treadmill. She performed three-minute stages starting at
23 m/min (0.8 mi/hr) and increasing 14 m/min (0.5 mph)
at each successive stage.20 She was encouraged to complete
each stage and progress to the next stage. The testing ended
when she indicated that she did not want to go to a higher
stage or could no longer walk at the current stage before
running. After testing, she did a cool down period at slower
speeds.
Expired gases were analyzed using a Medgraphs Met-
abolic Cart. A Hans Rudolph Mask of appropriate size was
used for collecting expired air. Individuals with DS have
decreased facial muscle tone, and using a mouthpiece to
collect expired gases to prevent expired air from escaping
can be challenging. The subject practiced walking on the
treadmill while wearing the mask to become familiar with
the procedure before testing.
Body Dimensions. Height and weight were mea-
sured and body mass index was calculated. Body mass in-
dex was determined by dividing her body weight in kilo-
grams by her height in meters squared (kg/m2) and was
used to indicate overall body composition.9
Flexibility Measurements. Flexibility was assessed
by the sit and reach test, ankle dorsiflexion with knee ex-
tension, Apley scratch test, and goniometric measurements
of hip internal rotation.
Gross Motor Assessment. Gross motor skills were
assessed using the Gross Motor Scales of the Bruininks-
Oseretsky Test of Motor Proficiency (BOTMP). The Gross
Motor Scales consist of four subtests to determine running
speed and agility, balance, strength, and bilateral coordina-
tion. A composite score was calculated from these four
subtests.
Anaerobic Power. A modification of the Margaria-
Kalamen power test was used to assess anaerobic capacities
or muscular power.21 In the modified power test, the sub-
ject ascended a flight of stairs as quickly as possible one
step at a time. In the typical Margaria-Kalamen power test,
healthy young athletes climb three steps at a time. Power
was determined by multiplying the subject’s body weight
in kilograms by the change in vertical height in meters
divided by time21: P (power) ⫽ [F (force), weight in kg] ⫻
D (vertical displacement]/T (time). Units are kilogram
meters per second (kg·m/sec). The vertical height was the
vertical rise from the base to the top of the flight of stairs.
Muscle Strength and Endurance Measurements.
Timed sit-ups in supine and back extensions in prone were
used to test trunk muscle strength and endurance. The
tests were modified because the child could not perform a
standard sit-up or push-up independently even while using
a 30-degree wedge. Assisted sit-ups were performed having
the subject focus on eccentric lowering of the trunk and
upper body. Back extensor strength and endurance were
determined by the number of prone extensions over a ther-
32 Lewis and Fragala-Pinkham
apeutic ball that she could complete without stopping for
more than a three-second rest. A 10-repetition maximum
(10 RM) was employed to assess shoulder flexion and ab-
duction; hip extension, adduction, and abduction; and
knee extension bilaterally for upper and lower limb
strength and endurance, respectively. A 10 RM is the max-
imal amount of weight that the subject can lift 10 times.9 A
10 RM was a safe assessment to employ with this subject as
less weight is placed on the joints when compared with a
one RM or three RM, the maximal amount of weight that
can be lifted one time or three times, respectively.
Home Exercise Training Protocol: Aerobic
Conditioning
Intensity. Maximal HR of individuals with DS is less
than that of peers without the disorder.13,22 Using the
ACSM guidelines of maximal training HR (220 ⫺ age ⫽ age
predicted maximal HR)9 would overestimate the HR of in-
dividuals with DS. According to Fernhall et al,22 maximal
HR of young adolescents with DS has was found to be
approximately 170 to 180 beats per minute. Initial aerobic
training intensity was 60% of 180 or a target HR of 101
progressing to 70% at a HR of 126 up to 80% at 144 beats
per minute.
Frequency. The initial aerobic program was per-
formed twice weekly increasing to three times per week.
Duration. Initial program required 10 to 15 minutes
daily increasing to 45 to 60 minutes daily.
Activities. Aerobic activities consisted of ribbon
wand exercises, walking through an obstacle course, and
stair climbing. The subject was videotaped doing the rib-
bon wand exercises and dancing, and she used the video-
tape to guide exercises at home. Music was used for moti-
vation during the movement activities.
Strength Training
Intensity. Intensity was progressed by increasing the
number of repetitions of sit-ups and trunk extensions and
increasing the number of repetitions and weight exercises
designed to strengthen the limbs.
Frequency. Initial strength training was performed
twice weekly increasing to three times per week by the
third week of the study.
Duration. Training began at 10 to 15 minutes daily
and was increased to 30- to 45-minute sessions.
Activities. Strength training included eccentric sit-
ups and concentric trunk extensions over a therapeutic
ball; knee extension and flexion and hip flexion in sitting;
leg lifts in side-lying, prone, and supine positions; squats,
toe raises, and heel raises; and hip abduction in the stand-
ing position using Theraband for resistance. Upper limb
exercises included resistance training using cuff weights
and Theraband in diagonal patterns, shoulder abduction/
adduction, and shoulder flexion/extension.
Documentation. The subject and her family kept a
daily chart of her exercise program, recording activities
performed, intensity, and duration. The child’s age, cogni-
tive level, motivation, and general physical status were
Pediatric Physical Therapy
considered, and exercises were altered according to these her exercises during the once-weekly physical therapy in-
factors. If she became bored with an activity, it was adapted tervention for carry over at home, and using a sticker chart.
to maintain her interest. The child’s mother supervised and assisted her throughout
Data Analysis. Mean values are reported for HR, RR, the training program, which contributed to the success of
and submaximal and peak VO2. Absolute values are pre- the home exercise program. Her parents did indicate diffi-
sented for the body mass index, flexibility, BOTMP Gross culty in continuing this type of program. They were
Motor Scales, Margaria-Kalamen power step test, and pleased with the success but could not keep up the inten-
strength training. A paired t test was used to determine sity. After the study ended, with input by the physical ther-
differences in pre- and posttraining performances where apist, they switched to a treadmill training program five
applicable. The p value was set at p ⫽ 0.05 for level of days per week for 30 minutes per session and strength
significance. training two days per week for 20 to 30 minutes with a
monthly physical therapy consultation. A few months
RESULTS later, they reported continued success with endurance, en-
Changes in posttraining submaximal treadmill tests hanced community mobility, and weight management.
are in Table 1. The subject demonstrated significantly This subject was able to demonstrate both aerobic and
lower HR (p ⫽ 0.008) and RR (p ⫽ 0.038) posttraining. strength improvements by performing a combined aerobic
However, her VO2 did not significantly change during ei- and strength exercise training protocol. Of the three car-
ther the submaximal protocol (Table 1) or highest VO2 diovascular variables, HR, RR, and VO2, she demonstrated
reached (Table 2). improvements in two areas: lower HR and RR at all stages
Body mass index did not change during the training on the submaximal stress test post training. No differences
period either (Table 2). Flexibility was within normal lim- were found in VO2. Not all cardiovascular changes occur at
its for the sit and reach test, ankle dorsiflexion with knee the same rate. Adaptation in HR and RR can occur more
extension, and Apley scratch test. She had a slight decrease quickly than changes in VO2.23 The program was conducted
in hip internal rotation at the beginning of the exercise for six weeks. A training program of longer duration may
program that was unchanged posttraining (Table 2). have resulted in enhanced VO2.
She demonstrated significant gains in gross motor These cardiovascular findings differ from those re-
skills posttraining (Table 2). Her composite point score ported by Miller et al18 and Varela et al.19 In those two
changed from 2 to 19 on the Gross Motor Scale of the studies, subjects were adolescents and young adults with
BOTMP. She demonstrated an almost 60% increase in an- DS who performed a 10-week program of walking/jogging
aerobic power as measured by the modified Margaria-Kal- and a 16-week rowing ergometry training regimen, respec-
amen power test (Table 2). Strength gains were observed in tively. The frequency was three days per week, and the
all measurements for the trunk and upper and lower limbs intensity was initially 55% progressing to 70%. In both of
(p ⫽ 0.014) (Table 2). these studies, subjects demonstrated increased endurance
posttraining by performing one minute longer on the max-
DISCUSSION imal stress tests, but subjects had no changes in cardiovas-
Factors contributing to the success of this program cular variables. The duration, intensity, and frequency fol-
were individualized exercises and parental support. Pro- lowed in these two research studies were those
gram adherence was 93% as calculated by the number of recommended by the ACSM for subjects without impair-
recommended sessions and the actual number of days that ment: 30 minutes per day, 60% to 80% intensity, three days
exercises were reported. Strategies used to motivate the per week.
subject were allowing her a choice of activities, videotaping Differences in this study compared with previous re-
search may result from differences in exercise training pro-
tocols. In this study, aerobic training intensity was higher,
TABLE 1 65% to 80% maximal HR versus 55% to 70%, duration was
Submaximal Treadmill Test longer (30 to 60 minutes vs 30 to 45 minutes), but the
Submaximal frequency of aerobic conditioning was the same (three
Treadmill Test Stage 1 Stage 2 Stage 3 Stage 4 times per week). Possibly the difference in findings in the
(mean values) (1.3 mph) (1.8 mph) (2.3 mph) (2.8 mph) current study and previous reports was the inclusion of the
Heart rate strength training program on alternate days of the week.
Pretraining 137 147 149 156* The subject in this study increased her 10 RM from three to
Posttraining 126 133 142 148† (p ⫽ 0.008) five pounds in knee extension as well as increasing her 10
Respiratory rate RM in hip extension, adduction, abduction, and increased
Pretraining 46 48 52 59*
Posttraining 43 45 47 50† (p ⫽ 0.038)
number of repetitions of sit-up and back extensions. Im-
VO2 mL/kg/min provements in trunk and lower limb strength could result
Pretraining 5.2 9.4 11.7 12.7* in a lower energy cost of gait as demonstrated by lower HR
Posttraining 8.8 8.9 10.4 12.7† and RR and increased performance time on the treadmill.
* Walked 1 min at stage 4. Because of the high correlation of leg strength to max-
†
Walked 2 min at stage 4. imal VO2 (r ⫽ 0.84) in subjects with DS, the rate limiter in

Pediatric Physical Therapy Conditioning and Strengthening in Down Syndrome 33

 TABLE 2
Pre- and Posttraining Measures

Measure Pretraining Posttraining

Submaximal treadmill test, peak VO2 17.6 ml/kg/min 18.6 ml/kg/min
Body mass index 28.2 kg/m2 28.2 kg/m2
Flexibility
Sit and reach WNL, touched toes Maintained
Ankle dorsiflexion with knee extension WNL, 0–20 deg Maintained
Shoulder backward reach WNL, finger tips touch Maintained
Hip internal rotation Slight decrease 0–30 deg bilaterally Maintained
BOTMP gross motor subtests
Composite point score 2 19
Margaria-Kalamen step test (mean of three trials) 14 kg 䡠 m/sec 22 kg 䡠 m/sec
Strength
Trunk flexion 0 sit ups, 3 eccentric sit ups with assistance 3 sit ups, 16 eccentric sit ups without assistance
Trunk extension 3 reps holding each for 3 sec 12 reps holding each for 5 sec
Hip extension 8 reps (R), 7 reps (L) 0 lb 2 sets of 10 reps with 3 lb
Hip adduction 9 reps bilaterally, 0 lb 2 sets of 10 reps with 3 lb
Hip abduction 1 set of 10 reps with 0.5 lb 1 set of 10 reps with 3 lb
Knee extension 1 set of 10 reps with 3 lb 1 set of 10 reps with 5 lb
Shoulder flexion 1 set of 10 reps with 1 lb 1 set of 10 reps with 4 lb
Shoulder abduction 1 set of 10 reps with 0.5 lb 1 set of 10 reps with 4 lb
WNL ⫽ within normal limits; BOTMP ⫽ Bruininks-Oseretsky Test of Motor Proficiency; reps ⫽ repetitions.

treadmill and upper body ergometry stress testing may be
skeletal muscle fatigue rather than cardiovascular fatigue.15
As previously noted, maximal stress is designed to strain
the cardiovascular system before causing muscle fatigue.
Individuals with impairment in the respiratory system or
musculoskeletal system may fatigue these systems before
fully stressing the cardiovascular system during a stress
test.
Fernhall et al24 demonstrated that adolescents and
young adults with DS had reduced cardiovascular endur-
ance when compared with peers with mental retardation
but without DS. Cioni et al25 and Horvat et al26 measured
decreased isokinetic torque, average power, and flexion/
extension ratios in subjects with mental retardation when
compared with subjects without disabilities. However,
these measures of strength were even lower in the group
with DS than in peers with mental retardation but without
DS. In these studies, subjects with DS demonstrated even
lower cardiovascular and strength measures when com-
pared with peers with mental retardation but without DS.
In 1994, Dyer27 conducted a circuit weight-training
program in an A-B-A design with 10 children and adoles-
cents with DS. She reported that subjects demonstrated a
lower mean resting HR, lower mean resting blood pressure,
and lower peak HR to a three-minute step test after a 13-
week strength training program. Oxygen consumption was
not measured in this study. This strength training program
resulted in changes in cardiovascular variables as noted by
lower resting HR and blood pressure.
The subject in this study displayed not only gains in
cardiovascular variables and strength measures, she also
demonstrated improved balance, coordination, and power
in gross motor tasks. Her score on the Gross Motor Scale of
BOTMP increased from 2 to 19. This scale consists of four
subtests that measure running speed and agility, balance,
strength, and bilateral coordination. Activities included in
the subtests were walking heel-toe on a line and on a bal-
ance beam, unilateral stance with eyes open and closed on
and off a balance beam, jumping up and down with and
without clapping hands and with and without touching
heels, standing broad jump, and running speed and agility
over a 45-ft distance.
She improved her score on the modified Margaria-
Kalamen power test from 14 kg·m/sec to 22 kg·m/sec. Since
her body weight did not change, the increased score would
require her to ascend the stairs more quickly. Her im-
proved balance, running, and coordination as noted by her
increased Gross Motor Scale score and by increased trunk
and lower limb muscle strength and endurance as noted by
her increased number of repetitions and 10 RM measure-
ments could account for her faster speed in stair climbing
for an improved anaerobic power score. However, stair
training was also part of the aerobic program, and she may
have experienced a practice effect.
Since the program was six weeks in length, the
changes in muscle strength and speed are a result of en-
hanced neural recruitment rather than changes in in-
creased muscle fiber size.28 Typically, prepubescent chil-
dren do not demonstrate changes in muscle fiber size, and
increased strength results from enhanced neural recruit-
ment and timing.
Two measurements were unchanged: flexibility and
body weight. Although change in flexibility was not a goal
of the program, decreased body weight was. Although she
did not lose weight, she did not gain weight either. To
demonstrate changes in body weight and body mass index,
this training program would have needed to include a pro-
gram of dietary management combined with the exercise
training protocol. Researchers suggest that exercise train-
ing alone will not make significant changes in body weight
and body mass index without dietary changes.29 Measure-
ment of the percentage of body fat would have provided

34 Lewis and Fragala-Pinkham Pediatric Physical Therapy

information on body composition. Since we did not use
skinfold measurements to assess body composition, we
cannot make any conclusions about body composition
changes after intervention.
The resting metabolic rate (RMR) also contributes to
the incidence of obesity in individuals with DS. The RMR is
the caloric expenditure to maintain homeostasis. The
lower the RMR is, the fewer calories that the individual
expends in maintaining body temperature, energy cost of
respiration, and other physiological functions at rest. With
a lower RMR, an individual is more likely to gain weight
8
even with a normal caloric intake. Luke et al reported that
prepubescent children with DS had significantly lower
RMRs than peers without DS. The two groups were
matched for age, weight, and percentage of body fat. Al-
though aerobic exercise does not significantly change the
RMR, it is higher in individuals with greater muscle mass.30
As previously noted, although prepubescent children can
improve their strength, this increase is thought to be en-
hanced by neural recruitment and not increased muscle
mass. Increased muscle mass is related to increased sex
hormones, especially testosterone.28 Future research on
the effects of strength training on the RMR in adolescents
with DS would be important to note for lifestyle manage-
ment to prevent the high incidence of obesity often seen in
postpubescent individuals with DS.
A limitation of this case study is that we did not have
information on the subject’s thyroid function. Yearly thy-
roid screenings from infancy to adulthood are recom-
mended for individuals with DS because of the high inci-
dence of hypothyroidism.31 Signs of hypothyroidism
include fatigue, weakness, muscle cramps or muscle aches,
weight gain or difficulty losing weight, cold intolerance,
depression, irritability, and memory loss. Since these
symptoms could affect the effectiveness of a fitness pro-
gram, it is important for therapists to obtain information
about thyroid functioning before initiating a fitness pro-
gram. In the future, other measures such blood pressure at
rest and during exercise and skinfold and girth measure-
ments would provide additional information about physi-
cal changes after strength and endurance training.
Clinical Implications
This study has several clinical implications. (1) Find-
ings from this study and those on aerobic conditioning and
strength performance suggest that to achieve cardiovascu-
lar benefits for children with DS, a combination program of
aerobic conditioning and strength training is more effec-
tive than aerobic conditioning alone. (2) Additionally, the
program has to be of a moderate to high intensity for a
minimum of 30 minutes for five to six days per week. The
exercise program must go beyond the suggested ACSM
guidelines for cardiovascular fitness training in persons
without impairment to be effective in individuals with DS.
(3) This program worked because of the dedication of the
parents and their interest in the child being more physi-
cally fit. Without strong parental support and the structure
they provided, the home exercise program would not have
Pediatric Physical Therapy
been effective. At the end of the study, the home program
was modified and the parents continued to carry out an
aerobic and strength program with their daughter. (4) The
program was adapted to the interests and attention level of
the subject. She could choose from a variety of activities on
a daily basis. Videotaping the weekly physical therapy in-
tervention program assisted the parents and child in fol-
lowing through with the program. (5) Physical activity has
to become part of a lifestyle for children and adolescents
with DS because of their higher risk of chronic diseases that
is worsened by obesity and a sedentary lifestyle.
SUMMARY AND CONCLUSION
In this case study of a child with DS, a home program
of combined aerobic conditioning and strength training of
moderate to high intensity, 30 to 60 minutes per day for
five to six days per week resulted in changes in cardiovas-
cular variables not reported in other studies employing
aerobic conditioning only. In individuals with DS, in
whom muscle strength and VO2 is very highly correlated,
combined aerobic and strength training protocols may be
necessary for the improvement of cardiovascular function.
Future research is need to investigate this hypothesis in a
larger group of children with DS compared with age- and
gender-matched peers without DS. A combined exercise
training protocol of longer duration of 10 to 12 weeks and
using a maximal stress test may result in enhanced VO2 in
subjects with DS that the authors did not document in this
study.
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Pediatric Physical Therapy
Concluzii:

1. Tratamentul recuperator, trebuie sa raspunda cerintei de baza a dezvoltarii si

cresterii copilului.
2. In perioada de dezvoltare a deprinderilor motorii de baza se pune
fundamentul dezvoltarii motorii viitoare.
3. Este obligatoriu sa tinem seama ca interventia kinetoterapeutului sa aiba loc
in aceasta perioada.
4. Un aspect important, dar si elementar de stiut este ca in aparitia limitarilor in
comportamentul motor in cazul copiilor cu Sindrom Down este
incapacitatea-dizabilitatea - de stabilizare a posturilor.
5. In programul specific kinetic trebuie dezvoltata fiecare deprindere
neuromotorie de baza, trebuie stimulata postura primara de baza.
6. Terapia prin joaca in cadrul procesului de recuperare are un succes mare in
randul acestor copii.
7. Sedinta de kinetoterapie trebuie sa inceapa cu manevre de masaj terapeutic,
acest lucru favorizeaza apropierea copilului de catre kinetoterapeut si apoi se
va continua cu un program de exercitii care contribuie la dezvoltarea fortei
musculare, a echilibrului, a mobilitatii articulare si a orientarii in spatiu.