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Why Passive Exercises Are Not Recommended for Late-Stage Dementia: The Role of Paratonia
12th May, 2025
Paratonia—a form of hypertonia characterised by involuntary, variable resistance to passive movement—is a common and debilitating motor disturbance in individuals with dementia, particularly in its later stages. Although passive movement therapy (PMT) is widely used to manage increased muscle tone, emerging research indicates that this approach may not only be ineffective but also potentially harmful for those with severe paratonia.
Prevalence and Impact of Paratonia in Late-Stage Dementia
Paratonia is observed in approximately 10% of early-stage dementia cases; however, its prevalence rises significantly to between 85% and 100% in late-stage dementia¹ ².
This condition severely impairs movement, making everyday care activities such as washing, dressing, and repositioning extremely challenging for both patients and carers¹ ².
Unlike rigidity associated with Parkinsonism or spasticity, paratonia is often misunderstood. This misunderstanding can lead to frustration and discomfort during care, increasing the emotional and physical strain on carers¹ ².
The Study: Does Passive Movement Therapy Help?
A multicentre, single-blind randomised controlled trial investigated the effects of PMT on muscle tone in nursing home residents with moderate to severe paratonia³. Participants were divided into two groups: one received PMT three times a week for four weeks, while the control group received no PMT.
-Primary outcome: Severity of paratonia, measured by the Modified Ashworth Scale (MAS).
-Secondary outcomes: Clinical global impression, carer burden, and pain during morning care.
Key Findings:
-After two and four weeks, participants receiving PMT showed no improvement in paratonia severity, clinical impression, carer burden, or pain compared to controls³.
-Earlier pilot data even suggested a trend towards worsening paratonia in some patients receiving PMT².
The study concluded that PMT has no beneficial effects and should not be recommended as an intervention for severe paratonia in late-stage dementia³.
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Why Passive Exercises May Not Work - And Could Be Harmful
Paratonia involves more than just stiff muscles. It reflects complex changes in both muscle tissue and nervous system function and may be exacerbated by conditions such as diabetes mellitus and the accumulation of advanced glycation end-products (AGEs) in muscle collagen¹.
Resistance in paratonia is involuntary and can worsen with external attempts at passive movement, potentially increasing discomfort, pain, and carer burden⁴ ⁵.
Moreover, unlike spasticity, the resistance in paratonia is variable and often increases with the speed and force of movement—making passive exercises particularly problematic⁴ ⁵.
Alternative Approaches and Recommendations
Given the lack of evidence supporting PMT—and the high prevalence of paratonia in advanced dementia—clinicians and carers are advised to:
Avoid routine use of passive movement exercises in individuals with severe paratonia.
Focus instead on comfort-oriented care, such as gentle positioning and the use of supportive devices (e.g., cushions) to minimise pain and the risk of contractures⁶.
Implement individualised care strategies that prioritise patient comfort and reduce unnecessary physical handling.
Conclusion
Passive movement therapy is not supported by current evidence as a beneficial intervention for paratonia in late-stage dementia. With prevalence rates reaching up to 100% in advanced cases, it is essential to understand the nature of paratonia and to adapt care accordingly to enhance quality of life for both patients and carers.
“PMT has no beneficial effects and should therefore not be recommended as an intervention in severe paratonia.”⁷
Care teams should receive appropriate education on paratonia and adopt alternative, evidence-based strategies to manage movement dysfunction in advanced dementia.
References
Hobbelen, J. et al. (2011) Prevalence, incidence and risk factors of paratonia in patients with dementia: a one-year follow-up study. Int Psychogeriatr, 23(7):1051–60. doi: 10.1017/S1041610210002449.
Drenth, H. et al. (2020) Paratonia in Dementia: A Systematic Review. J Alzheimers Dis., 78(4), 1615–1637. doi: 10.3233/JAD-200691.
Hobbelen, J. et al. (2012) Passive movement therapy in severe paratonia: a multicentre randomised clinical trial. Int Psychogeriatr, 24(5):834–44. doi: 10.1017/S1041610211002468.
Van Deun, B. et al. (2018) Paratonia in Flemish nursing homes: Current state of practice. Am J Alzheimers Dis Other Demen, 33(4):215–224.
Hobbelen, J. et al. (2003) The effect of Passive Movement Therapy (PMT) on the severity of paratonia: A partially blinded randomised clinical trial (pilot study). Tijdschrift voor Fysiotherapie, 113:132–137.
Van Deun, B. et al. (2019) Managing paratonia in persons with dementia: Short-term effects of supporting cushions and harmonic techniques. J Am Med Dir Assoc, 20:1521–1528.
Hobbelen, J.H. et al. (2012) Passive movement therapy in severe paratonia: a multicentre randomised clinical trial. Int Psychogeriatr, 24(5):834–44. doi: 10.1017/S1041610211002468.
** Note - the purpose of this blog is to give an overview of the product with some tips to consider on its use. This is not intended to be a substitute for professional or medical advice, diagnosis, prescription or treatment and does not constitute medical or other professional advice. For advice with your personal health or that of someone in your care, consult your doctor or appropriate medical professional.
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