What’s the Difference Between Tremors and Dyskinesia in Advanced Parkinson’s Disease?

Tremors and dyskinesia are both common symptoms of Parkinson’s disease — and although the two types of involuntary movements can sometimes appear similar, they’re different at all stages of the disease, including the advanced stages.

“People often mix up tremors and dyskinesia because they’re both involuntary extra movements,” says Todd Herrington, MD, PhD, a neurologist at Massachusetts General Hospital and an assistant professor of neurology at Harvard Medical School in Boston.

What Are Parkinson’s Tremors?

What Is Dyskinesia in Parkinson’s Disease?

Herrington points out that you can see an example of dyskinesia if you look at videos of the actor Michael J. Fox, who has Parkinson’s disease. “Usually,” he says, “when [Fox] is on camera, he has some dyskinesia, or extra movements that are involuntary.”

Are Tremors or Dyskinesias Painful?

Tremors are almost never painful, says Herrington.

How Are Tremors and Dyskinesia Treated?

It’s therefore important for a neurologist to be able to tell the difference between the two symptoms, he says, and to adjust the medications accordingly.

Herrington points out that not all people are similarly bothered by tremors or dyskinesia. Take tremors, for example. “There are some people who have a very small tremor and it bothers them immensely,” he says. “Other people have quite a substantial tremor and really don’t seem to care about it very much.”

When it comes to treating tremors, doctors may start out by asking people how much the symptom bothers them. “As a physician, you can categorize which symptoms people have or the level of severity,” says Herrington, “but it’s always really important to ask the person what bothers them. The most objectively severe symptom may not be the one that bothers them the most.”

As for dyskinesia, some people don’t notice it at all, he says. “[With dyskinesia] there is often a divergence between how much they notice and are bothered by it and how much their loved ones notice and are bothered by it.”

How Are Tremors and Dyskinesia Experienced by Caregivers?

People with Parkinson’s disease can experience their condition much differently from their caregivers or spouses. “Sometimes being in the ‘off’ state looks more comfortable to the caregiver because the person is still, and can even seem kind of calm,” says Herrington. “But for the person with Parkinson’s, they experience that ‘off’ state as very uncomfortable. They may describe it as feeling trapped because they want to move but they can’t.

The caregiver, however, may feel bothered by the increased movement, he says, and think that the person is taking too much medication. “There can be a real disconnect there between what the patient would want and what the caregiver might think is best,” says Herrington. “It’s not always the best thing to try to get rid of every last bit of dyskinesia, because the person might be less comfortable in that state.”

How Can People Manage Parkinson’s-Related Dyskinesia and Tremors?

When it comes to managing dyskinesia and tremors, it’s important to strike a balance between too much medication and too little. “You can have too much dopamine medication [levodopa], which can make dyskinesias occur earlier and can make them worse once they start,” says Herrington. “Then there’s the effect of not enough dopamine medication, which can leave people with this ‘off,’ slow, stiff feeling."

The more people know about the treatment options for Parkinson’s, the better they tend to feel. “I share with [care partners] that we can’t necessarily find the perfect dose that gives [the patient] relief from the slow, stiff, ‘off’ symptoms and causes no dyskinesias. For some patients, finding that middle ground is very difficult," says Herrington.

“The person and the caregiver and loved ones need to be aware of the necessary trade-offs that are involved,” he continues. “Only then can you make an informed decision on how best to move forward.”