You may have heard people with Parkinson’s disease talk about being “on” or “off”. It may look like feeling great and moving freely one moment, then suddenly slowing down or freezing the next. These ups and downs are known as motor fluctuations. They are a standard part of living with Parkinson’s as the disease and its treatment evolve.
Motor fluctuations can be confusing at first. Why do symptoms seem to come and go? Is it the medication? Is it the disease itself? Well, it’s a bit of both, and understanding how and why these changes occur is key to managing Parkinson’s more effectively.
This blog will help explain what motor fluctuations are, why they happen, what they look like in daily life, and how doctors can help smooth them out.
Motor fluctuations are variable responses to dopaminergic medication (Levodopa) observed in Parkinson’s disease patients, in which periods of effective symptom control (designated “on” states) alternate with periods of poor response (designated “off” states).
These fluctuations are often described as:
- “On” periods → when medication is working well
- “Off” periods → when the effect of medication wears off and Parkinson’s symptoms return.
One of the most frequently recognized motor symptoms in patients is tremors. However, motor fluctuations encompass more than just this symptom; they can significantly affect various aspects of daily life.
Motor fluctuations can vary from mild to severe and often follow a pattern. Some common signs include:
- Feeling stiff, slow, or frozen before the next dose
- Tremor returning after being well-controlled earlier in the day
- Involuntary “wiggling” or jerky movements when the medication is strongest
- Unpredictable changes in movement, speech, or energy
- Difficulty walking or suddenly freezing, especially in doorways or crowds
Many people find it helpful to keep a medication and symptom diary, noting when doses are taken and how they feel throughout the day. This helps doctors fine-tune medication schedules and recognize fluctuation patterns.
A typical example of motor fluctuation occurs when you wake up feeling stiff and sluggish. After taking your morning medication, you may experience significant improvement within an hour, only to have tremors or slowness reemerge as the time for your next dose approaches. This scenario represents one of the most common types of motor fluctuations, though they can manifest in various ways as well.
Not all fluctuations are the same. Here are some of the most common types and what they mean:
“Wearing Off”
It is the most frequent type of motor fluctuation. It happens when each dose of medication doesn’t last as long as it used to. Symptoms return before the next scheduled dose, often in a predictable pattern. It can be predictable or unpredictable.
Example: You take your medication at 8 a.m., feel good until around 11 a.m., and then notice tremors or stiffness returning around lunchtime.
On/Off Phenomenon
These changes are less predictable. You might suddenly go from moving well (“on”) to feeling “off” even when your last dose was recent. These abrupt transitions can be frustrating and are not always linked to medication timing.
Levodopa-Induced Dyskinesias
When dopamine levels peak, some people experience extra, involuntary movements — twisting, writhing, or fidgety motions called dyskinesias. While different from “off” symptoms, they can still interfere with comfort and daily activities.
Failure of the “on” response
It happens when you are in an “OFF” state and your medication doesn’t seem to work at all.
Freezing of gait and Other Motor Instabilities Freezing of gait (FOG)
In this one, you may experience transient episodes of an inability to start or continue walking, often occurring during “off” periods. Moreover, episodes of postural instability and akinesia (difficulty starting movement) may occur.
The four most common types of motor fluctuations are Wearing Off, the On/Off Phenomenon, Levodopa-Induced Dyskinesias, and the Failure of the “on” response. Motor fluctuations occur in approximately 30 to 40% of patients during the first five years of treatment, and in at least 60% of patients after ten years of living with the disease. This leads to an important question: why do I experience motor fluctuations?
Motor fluctuations develop for several reasons, and they often involve a mix of biological and treatment-related factors:
- Disease progression: Over time, the brain loses more dopamine-producing cells. It reduces its ability to “buffer” dopamine levels between doses.
- Medication timing and absorption: Levodopa’s effect depends on how it’s absorbed in the gut and transported to the brain. Delayed gastric emptying or high-protein meals can change how quickly it works.
- Medication duration: After years of therapy, the body may process levodopa faster, shortening its duration of benefit.
- Neural sensitivity: The brain’s dopamine receptors can become more sensitive to changes in dopamine levels, leading to greater swings between “on” and “off” states.
- Genetic influences: A gene called PRKN may affect the age of symptom onset and the later development of motor complications.
The medications, the progression of the disease, and the genetic factors of a Parkinson’s disease patient all play a role in triggering motor fluctuations. It’s also important to consider that certain risk factors can contribute to the development of these fluctuations.
- Early onset of the disease
- Extended duration of the disease
- Presence of more severe non-motor symptoms, such as anxiety and depression
- Abnormal gastric emptying
- Patients receiving higher cumulative doses of levodopa
- Greater baseline severity of symptoms
Once you are aware of your risk factors, your movement disorder specialist will take charge of managing your treatment.
Although motor fluctuations are common, there are many ways to reduce their impact and regain smoother control. The management of “wearing off” will change for individuals and requires a trial-and-error approach.
Dietary adjustments
Dietary protein competes with levodopa for transport in the gut and across the blood-brain barrier, which can lower its peak after ingestion.
It can be recommended to avoid protein at the time of levodopa intake on an empty stomach, 30 to 60 minutes before or 60 to 90 minutes after a meal.
Medication Adjustments
Doctors may suggest smaller, more frequent doses of levodopa or extended-release formulations to keep steadier dopamine levels. Avoiding protein-heavy meals around dosing time can also improve absorption.
In addition to levodopa, other classes of medications can be used to enhance its effects:
- MAO-B inhibitors (like rasagiline or selegiline) slow dopamine breakdown.
- COMT inhibitors (like entacapone or opicapone) prolong levodopa’s action.
- Dopamine agonists (like pramipexole or ropinirole) mimic dopamine’s effects directly.
Sometimes, levodopa and other medications may not be sufficient to manage your symptoms effectively. In such cases, more continuous treatment options may be considered, including:
- Levodopa intestinal gel (Duopa) — a pump delivers medication directly into the intestine for steady absorption.
- Apomorphine injections or infusions — provide rapid “rescue” during sudden “off” episodes.
- Deep Brain Stimulation (DBS) — a surgical therapy that helps stabilize movement by regulating brain circuits.
Lifestyle and Supportive Care
Exercise, physical therapy, and stress management can help reduce “off” time and improve overall function. Even gentle daily movement, stretching, walking, or tai chi, supports better balance and flexibility.
Recognizing motor fluctuations early can make a big difference in quality of life. With the right combination of medication adjustments, lifestyle strategies, and medical guidance, many people regain smoother and more predictable control of their symptoms.
References
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Freitas, M. E. (2017). Motor complications of dopaminergic medications in Parkinson’s disease. Journal of Movement Disorders, 10(Suppl 2), S37–S44. https://doi.org/10.1055/s-0037-1602423
Very informative
Thanks