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Navigating Parkinson's Symptoms:
Managing Dyskinesia & OFF Time

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.

Tips for Managing Dyskinesia

Dyskinesia

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 when a patient is anxious or stressed.

Typically emerging after several years of levodopa treatment, the primary medication for PD, dyskinesia may be mitigated by adjusting dosage or trying alternative dopaminergic medications that target dopamine production in the brain. Interestingly, younger individuals with PD tend to experience motor fluctuations and dyskinesias earlier in response to levodopa treatment. Managing dyskinesia in Parkinson’s disease often requires a multifaceted approach tailored to your individual needs and preferences. Regular communication with your healthcare team and proactive self-care can help optimize symptom management and enhance your quality of life.

Tips for Managing Dyskinesia:

  • Medication Management: Work closely with your healthcare provider to adjust your medication dosage and schedule to minimize dyskinesia while maintaining symptom control. Amantadine can be an effective tool for controlling dyskinesia, while still effectively managing other Parkinson’s symptoms.
  • Stress Reduction: Practice stress-reduction techniques such as mindfulness meditation, deep breathing exercises, or yoga to help manage stress and anxiety, which can exacerbate dyskinesia. Incorporate relaxation techniques into your daily routine to promote a sense of calmness and reduce muscle tension, potentially alleviating dyskinesia symptoms
  • Physical Therapy: Engage in regular physical activity and consider working with a physical therapist to improve muscle control and balance, and reduce dyskinesia. Practicing Gait training exercises to improve walking patterns and reduce the risk of falls.
  • Dietary Considerations: Some individuals find that certain foods or drinks can worsen dyskinesia. Keeping a food diary and identifying triggers can be helpful.

OFF Time

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.

Tips for Managing OFF Time:

  • Optimize Medication: Work with your healthcare provider to adjust your medication regimen to minimize OFF time. This may involve changing dosages, adding or switching medications, or exploring advanced therapies.
  • Timing of Medications: Take medications on a consistent schedule to maintain more stable levodopa levels throughout the day. Set alarms or use pill organizers to ensure you are taking your medications on time. 
  • Stay Active: Engage in regular physical activity to help manage Parkinson’s symptoms and reduce the frequency of OFF periods. Exercise can improve mobility, balance, and muscle strength, as well as enhance the effectiveness of medications. Aim for a combination of aerobic exercise, strength training, and flexibility exercises tailored to your abilities.
  • Rescue Medications: Discuss the use of rescue medications with your healthcare provider for managing sudden OFF episodes. These medications, such as apomorphine injections or sublingual formulations of levodopa, can provide rapid relief when you experience OFF periods and help bridge the gap until your next scheduled dose.
  • Device-Aided Therapies and Non-Pharmacaolgocial Approaches: Explore non-medication strategies such as deep brain stimulation (DBS), subcutaenous infusions, exercise, physical therapy, and occupational therapy to manage OFF time symptoms and improve overall quality of life.

Tremor

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.

Tips for Managing Tremor:

  • Medication Management: Certain medications, such as levodopa, dopamine agonists, and anticholinergics, may help alleviate tremor.
  • Physical and Occupational Therapy: Engage in exercises and techniques recommended by physical and occupational therapists to improve muscle control and reduce tremor.
  • Stress Management: Practice stress-reduction techniques such as mindfulness, relaxation exercises, and hobbies to minimize tremor exacerbation due to stress.

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