Dyskinesia
Reviewed by Dyskinesia refers to involuntary, uncontrolled movements that can affect the face, arms, legs, or trunk. They can look fluid or dance-like, although they may also appear as jerking movements or sustained muscle spasms.
Dyskinesia in Parkinson’s disease arises as a side effect of levodopa therapy. It is not one of the motor symptoms of Parkinson’s itself, like stiffness, tremors, and slowness of movement. Instead, it is a complication of treatment for these symptoms.
Levodopa-induced dyskinesia affects many people with Parkinson’s disease. It occurs in nearly 40% of people with Parkinson’s after four to six years of levodopa treatment.
A five-year study of 672 people with Parkinson’s found that 18.9% had dyskinesia at the start of the study. Among the 434 participants evaluated five years later, 42.6% had dyskinesia.
What causes dyskinesia?
Parkinson’s disease arises from the loss of dopamine-producing cells in the brain. Because dopamine plays an important role in controlling movement, Parkinson’s disease is characterized by progressively worsening motor symptoms. These symptoms include tremor, slowness of movement, rigidity, and impaired posture.
Levodopa is widely considered the gold-standard treatment for these motor symptoms. Levodopa is a precursor to dopamine, meaning the brain can convert it into dopamine to help compensate for reduced dopamine levels in people with Parkinson’s.
Levodopa is commonly administered orally. The problem is that oral levodopa has a short half-life, meaning the amount of levodopa in the blood drops by half over a relatively short period. Because of this short half-life, levodopa levels in the blood can rise and fall between doses instead of remaining steady.
These fluctuations can lead to uneven stimulation of dopamine receptors in the brain. Scientists believe this contributes to the development of dyskinesia.
Risk factors
Scientific research has identified several risk factors for dyskinesia in Parkinson’s disease. A 2023 genetic study used data from nearly 2,800 people with Parkinson’s disease. The study found that being female and having a younger age at Parkinson’s onset were associated with a higher risk of developing dyskinesia.
A separate five-year study identified additional factors associated with dyskinesia in Parkinson’s disease. These include a longer duration of disease, longer time on levodopa treatment, and higher levodopa doses. Lower body weight, greater pain severity, and fluctuations in Parkinson’s motor symptoms were also associated with dyskinesia in people with Parkinson’s.
Factors linked to dyskinesia can include:
- being female
- younger age at Parkinson’s disease onset
- longer duration of disease
- longer time on levodopa treatment
- taking levodopa at higher doses
- lower body weight
- greater pain severity
- fluctuations (on and off periods) in Parkinson’s motor symptoms
Types of dyskinesia in Parkinson’s disease
Doctors classify levodopa-induced dyskinesia according to when involuntary movements occur during the levodopa dosing cycle. The main forms are peak-dose dyskinesia, diphasic dyskinesia, and off-period dystonia, which occurs when levodopa levels are low, such as overnight or in the early morning.
Peak-dose dyskinesia
Peak-dose dyskinesia is the most common form of levodopa-induced dyskinesia. It appears around the time of peak levodopa effect, when dopamine stimulation is highest.
The movements usually take the form of chorea, which involves fidgety, dance-like movements. Peak-dose dyskinesia can also manifest as ballism, which involves involuntary flinging or throwing movements of the arms or legs. It may also show up as stereotypy, which involves repetitive movements or vocalizations such as:
- body rocking
- hand flapping
- head nodding
- repeating phrases
Less commonly, peak-dose dyskinesia can involve dystonia or myoclonus. Dystonia is characterized by involuntary twisting and sustained muscle contractions that can cause abnormal movements or postures. Myoclonus involves brief, sudden muscle jerks.
Diphasic dyskinesia
Diphasic dyskinesia is less common. Estimates suggest it affects about 3% to 20% of people with Parkinson’s who experience motor fluctuations.
Diphasic dyskinesia gets its name because involuntary movements occur twice during a single levodopa dosing cycle: once as the medication begins to take effect and again as it wears off. The movements improve in between, while the medication is working.
For this reason, some medical professionals call diphasic dyskinesia dyskinesia-improvement-dyskinesia. It often involves large, uncontrolled movements affecting one or both legs and is more common in people with young-onset Parkinson’s.
Among the main types of dyskinesia, diphasic dyskinesia is generally considered the hardest to treat.
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| Category | Peak-dose dyskinesia | Diphasic dyskinesia |
|---|---|---|
| Relationship to levodopa cycle | Occurs around the time of peak levodopa effect, when dopamine stimulation is highest | Occurs as levodopa starts working and again as it wears off, with improvement in between |
| Typical symptoms | Fidgeting, dance-like movements, flinging or throwing movements, repetitive movements or vocalizations | Large, uncontrolled movements affecting one or both legs |
| Treatment difficulty | Generally less difficult to treat than diphasic dyskinesia | Generally the hardest dyskinesia type to treat |
| Rarity | More common | Less common |
Treatments and management options for dyskinesia
Treating dyskinesia can be very challenging. On the one hand, doctors want to administer enough levodopa to control Parkinson’s motor symptoms. On the other hand, higher levodopa doses and fluctuations in medication levels can trigger or worsen dyskinesia.
Treatment strategies range from simple changes in how medication is timed to advanced treatments such as deep brain stimulation, which uses surgically implanted electrodes to deliver electrical stimulation.
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| Treatment option | Description |
|---|---|
| Changes to levodopa treatment | Taking smaller, more frequent doses; using longer-acting formulations such as Rytary; or using continuous levodopa-based infusion treatments such as Vyalev |
| Amantadine treatment | Taking amantadine, a medication that can reduce dyskinesia but may cause side effects such as nausea and dizziness |
| Deep brain stimulation | Surgically implanting electrodes in the brain that deliver electrical impulses to help control Parkinson’s symptoms, including dyskinesia |
Medication timing and dosage adjustments
One of the simplest treatment options for dyskinesia in Parkinson’s disease is splitting the daily levodopa dose into smaller, more frequent doses. This can help reduce fluctuations in blood levodopa levels that can contribute to dyskinesia.
Extended-release formulations like Rytary (carbidopa/levodopa) take this basic idea further. In a clinical trial, people with Parkinson’s taking Rytary needed fewer doses per day than those taking immediate-release carbidopa/levodopa. They also had more on time without troublesome dyskinesia, meaning more time when the medication was controlling Parkinson’s symptoms without dyskinesia that interfered with daily activities.
For advanced Parkinson’s disease, infusion systems can provide a continuous supply of levodopa, helping reduce symptom fluctuations associated with oral dosing. Vyalev (foscarbidopa and foslevodopa) is an infusion therapy approved by the U.S. Food and Drug Administration (FDA) in 2024. It uses a pump to deliver the medication continuously under the skin.
Research suggests that Vyalev may give people with Parkinson’s disease close to three additional hours of on time without troublesome dyskinesia per day, compared with about one additional hour with oral immediate-release carbidopa/levodopa. Studies have also found that the treatment can increase “good on” time, meaning on time with no dyskinesia or with dyskinesia that is not troublesome.
Targeted medications: amantadine formulations
Glutamate and dopamine are different chemicals that help brain cells communicate. Amantadine for dyskinesia works differently from levodopa and affects both glutamate and dopamine signaling in the brain. This can help reduce the involuntary movements associated with levodopa-induced dyskinesia.
The older immediate-release version, Symmetrel (amantadine), is typically taken two or three times per day.
Gocovri (amantadine) for dyskinesia is an extended-release formulation taken once nightly. In 2017, it became the first drug specifically FDA-approved to treat levodopa-induced dyskinesia.
Side effects of amantadine can include:
- low blood pressure
- nausea
- insomnia
- confusion
- paranoia
- dizziness
- hallucinations
- leg discoloration
Speak with your doctor if you are taking any form of amantadine and experience any of these side effects.
Advanced surgical and noninvasive interventions
When medication adjustments are not enough, deep brain stimulation (DBS) for dyskinesia may be an option for some people. DBS involves surgically implanting electrodes in the brain that deliver electrical stimulation. Clinical evidence shows that DBS can reduce both dyskinesia and off time, when Parkinson’s symptoms are less well controlled.
Researchers are also exploring noninvasive brain stimulation for people with Parkinson’s disease and dyskinesia. A two-patient case report using repetitive transcranial magnetic stimulation found short-term reductions in dyskinesia severity without medication changes. However, the findings are preliminary, and larger controlled studies are needed to determine how effective and lasting the treatment may be.
Daily coping strategies and lifestyle adjustments
People living with a chronic condition like Parkinson’s may find that small, sustainable habits can support both physical and emotional well-being in daily life. Some daily strategies and adjustments may also help with managing dyskinesia in Parkinson’s.
Stress management
Chronic stress can make existing health problems worse over time. Stress can also bring out dyskinesia. Because of this, finding healthy ways to manage stress may be especially useful for people who notice this connection.
The U.S. Centers for Disease Control and Prevention (CDC) recommends simple daily stress-reducing habits. These include taking breaks from news and social media, practicing deep breathing or stretching, and keeping a journal. Writing down things you are grateful for can also help ease day-to-day stress.
Connecting with other people is another habit the CDC lists among its recommended coping strategies. This can include spending time with family, friends, or other trusted people in the community.
Sleep hygiene
Good sleep hygiene means building daily habits that support consistent, restful sleep. This includes going to bed and waking at about the same times each day, including weekends, and keeping the bedroom cool, dark, and quiet. Most adults need seven to nine hours of sleep each night, though needs vary with age and individual health status.
Reducing noise and light in the bedroom, for example with blackout curtains or a white-noise machine, can make it easier to fall asleep and stay asleep. The CDC also advises turning off electronic devices at least 30 minutes before bed and avoiding large meals, alcohol, and caffeine in the afternoon or evening.
Evidence suggests that poor sleep may raise the risk of dyskinesia in people with Parkinson’s disease.
Staying active safely
The CDC publishes physical activity guidance specifically for adults with chronic health conditions and disabilities. It recommends talking with a healthcare professional or physical activity specialist about the types and amounts of activity that are appropriate for an individual’s abilities.
Some people with Parkinson’s disease find that exercise can substantially ease dyskinesia. For others, however, exercise can make dyskinesia worse. The reasons are not always clear but may include medication timing, physical stress, or other individual factors.
If exercise worsens Parkinson’s symptoms or dyskinesia, speak with a member of your healthcare team about how to adjust your activity safely.
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