Do your Parkinson’s disease symptoms return between doses of medication? You may be experiencing motor fluctuations, which can gradually develop after years of treatment. Motor fluctuations are common as Parkinson’s disease progresses, but you can work with your neurologist to find new treatment options that manage your symptoms better.

In this article, we’ll explain what motor fluctuations are, why they develop, and how they can be treated. Every person is different, so your doctor will tailor a plan that works best for you.

What Are Motor Fluctuations?

Motor fluctuations are changes in how well you move as your medication — usually levodopa/carbidopa — stops working well at the current dose.

The brain needs a chemical called dopamine to help movement. In Parkinson’s disease, the brain gradually stops producing dopamine, leading to symptoms such as slowed movement, tremors, and rigidity (when muscles feel stiff or resistant to motion).

At the early stage of Parkinson’s, just a few dopamine-producing cells are affected, and symptoms may be mild. Levodopa therapy helps by giving the brain the building blocks to make more dopamine. However, as the disease progresses and more cells are lost, the initial dose isn’t enough to relieve symptoms. Motor fluctuations are often a sign that the current dose is wearing off more quickly, so it may be time to adjust your treatment.

Motor fluctuations can also include dyskinesia, a movement disorder that can affect the face, arms, legs, or trunk. These involuntary movements can look like jerking or writhing, and some people also feel muscle spasms. Dyskinesia isn’t one of the symptoms of Parkinson’s disease — it’s a side effect of levodopa (often called levodopa-induced dyskinesia).

Over time, brain cells may become more sensitive to changes in levodopa levels. This can cause Parkinson’s symptoms to return when the levodopa wears off and dyskinesia to appear when levels peak. Treatment adjustments can help manage both.

What Are ‘On’ and ‘Off’ Times?

As you develop motor fluctuations, you may notice periods when your medication is most and least effective. These are also called “on” and “off” times. Your “on” time is when medication helps your body ease movement symptoms. “Off” time is when the effects wear off and symptoms start returning.

According to the American Parkinson Disease Association, “on” and “off” times can be either predictable or unpredictable.

Predictable motor fluctuations include:

• Wearing “off” — Symptoms return before your next scheduled dose, which is the most common motor fluctuation.
• Morning “off” — You wake up with symptoms because you haven’t taken your first dose of levodopa yet.

Unpredictable motor fluctuations include:

• Partial “on” — A dose provides only limited relief.
• Delayed “on” — Levodopa doesn’t kick in as fast as expected.
• Dose failure — A dose doesn’t work at all.
• Unpredictable “off” — Symptoms return without a clear pattern or connection to dosing.

Members of MyParkinsonsTeam have described how challenging it can be to manage “off” times. “It’s one of the hardest parts of living with Parkinson’s because we need to time our activities around our medication schedule,” wrote one member. “I don’t mind being ‘off’ when I don’t have much to do, but I need to be ‘on’ around my family or during meetings.”

What Are the Risk Factors for Motor Fluctuations?

Certain factors may increase the chance of developing motor fluctuations.

• Slow gut movement — If Parkinson’s affects how quickly food moves through your digestive system, it can slow the absorption of levodopa and lead to more “off” time.
• High-protein meals — Protein competes with levodopa for absorption in the intestines, which can reduce how much medication your body uses.
• Younger age at diagnosis — People diagnosed at a younger age are more likely to develop motor fluctuations sooner because they’ve had Parkinson’s longer.
• High levodopa use — Taking a high dose raises the risk of dyskinesia when the drug is at its peak.
• Disease severity — People in advanced stages of Parkinson’s may experience more motor fluctuations.

How Can You Manage Motor Fluctuations?

Many MyParkinsonsTeam members experience motor fluctuations as their disease progresses. “My first ‘off’ time made me feel afraid. I’ve learned to be kinder to myself,” one member shared.

If you need more support, ask your doctor about mental health resources that can help.

Motor fluctuations can greatly affect your quality of life, but you can work with your healthcare team to reduce “off” time and find a treatment plan that works for you. They may suggest changing your diet, adjusting your treatment plan, or trying certain procedures.

Dietary Changes

Some clinicians may suggest changing your diet or eating schedule to promote better medication absorption in your gut. For example, they may suggest taking levodopa on an empty stomach or avoiding protein-rich meals near your dose time.

Dosing Adjustments

Adjusting your medication dosage is often the first step to managing motor fluctuations. For example, your doctor may suggest taking your medication more often. Finding the right schedule can take some trial and error, so regular follow-up with your doctor as you track symptoms is important.

Other Delivery Strategies

If swallowing pills isn’t working well anymore, your doctor may suggest alternative delivery methods such as:

• Inhalants — Inbrija is an inhaled levodopa powder used between regular doses to ease sudden “off” periods.
• Infusions — Medications such as Duopa and foscarbidopa/foslevodopa (Vyalev) can be delivered continuously through a small pump (placed surgically near your belly button) to your intestine for better absorption.

Add-On or Alternative Medications

Several types of drugs can help manage motor fluctuations, either on their own or alongside levodopa. Depending on your symptoms and a drug’s potential side effects, your doctor may suggest one of these options:

• Long-acting levodopa/carbidopa (Crexont, Rytary) — These extended-release formulations help medication effects last longer.
• Amantadine (Gocovri, Osmolex ER) — This drug is used alone or with levodopa to treat tremors or help prevent dyskinesia.
• Istradefylline (Nourianz) — This add-on medication helps reduce “off” time without worsening dyskinesia.
• Anticholinergics such as trihexyphenidyl and benztropine mesylate — These are used alone or as add-on treatment to help with tremors, drooling, and dystonia (when a muscle stiffens).
• Catechol-o-methyltransferase (COMT) inhibitors — These add-on treatments extend each levodopa dose. Examples include entacapone (Comtan), levodopa/carbidopa/entacapone (Stalevo), opicapone (Ongentys), and tolcapone (Tasmar).
• Dopamine agonists — These can be taken alone or with other medications to mimic dopamine in the brain. Examples include apomorphine (Apokyn), apomorphine hydrochloride (Onapgo), pramipexole, pramipexole dihydrochloride, and ropinirole.
• Monoamine oxidase B (MAO-B) inhibitors — These can be used alone or as add-ons to help preserve dopamine in the brain. Examples include rasagiline (Azilect), safinamide (Xadago), and selegiline (Eldepryl, Zelapar).

Ultrasound

Your doctor may recommend trying focused ultrasound to help restore movement. This noninvasive procedure uses ultrasound waves to target the brain area causing symptoms. The waves create a small lesion that blocks abnormal brain signals and helps restore smoother movement.

Deep Brain Stimulation

Deep brain stimulation (DBS) is a surgical option that may help reduce motor fluctuations. Electrodes are placed in the brain area that controls movement, and they connect to a small device (called an implantable pulse generator) implanted under the skin in the chest or abdomen. When this device is activated, it blocks abnormal signals to improve motor control.

One MyParkinsonsTeam member shared their experience with DBS: “I wasn’t sure if I wanted to be awake during surgery, but I’m so glad I was. The moment they touched the correct spot, the tremors stopped, and I felt at peace.”

Join the Conversation

On MyParkinsonsTeam, people share their experiences with Parkinson’s disease, get advice, and find support from others who understand.

Have you been experiencing motor fluctuations lately? Let others know in the comments below.