Understanding the Difference Between Dyskinesia, OFF time, and Tremor in Parkinson’s Disease

Although both dyskinesia and OFF episodes are common aspects of living with Parkinson’s disease and become more prevalent later in the disease course. Levodopa-induced dyskinesia often involves involuntary muscle movements such as twitches, jerks, twisting and writhing. While “OFF” time occurs when Levodopa is wearing off and the patient has less control of their movements. These are referred to motor fluctuations.

While differentiating between dyskinesia and OFF episodes can be challenging, this article aims to highlight the distinguishing factors of each and discuss the different methods in which they can be managed.

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Dyskinesia is an involuntary muscle movement and irregular in motion. Patients may experience writhing or wriggling in their arms or feet, rocking or head bobbing, or swaying. Dyskinesia ranges in severity and may affect only part of the body, such as one leg or arm, or the whole body. Dyskinesia can also affect the mouth and face (lip pursing movements). For some patients it is a minor annoyance. For others it causes embarrassment and may interfere with daily activities such as feeding, dressing, writing, walking, and balance. Dyskinesia usually occurs when the level of levodopa is highest in a patient. A patient may experience kicking leg dyskinesia when their medications start to kick-in and wear-off, but this is very uncommon. Dyskinesia often increases while a patient is anxious or stressed.

Unlike dyskinesia, OFF time refers to when the level of levodopa is lowest in a patient and a PD medications are not working well. For patients, OFF symptoms may include an increase in tremor (rhythmic, regular motion of hands, feet, or jaw), increase in clumsiness or slowness of movement, more shuffling when walking, and muscle cramping or stiffness.

Patients also may experience a number of other non-motor OFF symptoms such as anxiety, depression, apathy, sweating, urinary urgency, or pain. Similar to dyskinesia, OFF episodes range in severity. For some patients, these episodes are a minor annoyance. For others, OFF time can cause embarrassment, interfere with daily activities, or cause walking and balance issues. Like dyskinesia, OFF episodes may be more frequent and more severe when a patient is stressed or anxious.

A tremor in Parkinson’s disease can appear in two ways: Resting and Action tremor. Restring Tremor refers to when your body is still and relaxed, for example when lying in bed. The most common manifestation of this type of tremor is called “pill-rolling” tremor, which typically looks like you are trying to roll a pill between the thumb and index finger. An action tremor usually occurs when the patient is in action, like trying to hold an object or drink from a cup.  Typically, a tremor starts in the hand before expanding through the rest of the arm. Occasionally, tremor may start in the foot, before spreading throughout that same leg. After many years, tremor may spread and start to affect the other side of the body.  For some patients, tremor may be the first noticeable symptom to manifest, but of course this varies from person to person and it is not possible to predict who will develop tremor.

Like dyskinesia and OFF time, tremor can worsen with an increased level of stress and anxiety. There is no cure for tremor; however, there are ways to manage it through Parkinson’s medications, stress relief and device aided therapies.

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