Motor Fluctuations or "OFF" Times in PD

Motor fluctuations are changes in the ability to move and are also referred to as “on-off” times. "On" is when Parkinson's medications are effective and motor and non-motor symptoms are controlled. "Off" time is when Parkinson's symptoms — motor and/or non-motor — return between medication doses. "Off" time may occur in the morning, before the first dose of medication, or during the day, between medication doses. When it happens between medication doses it may be referred to as "wearing off". "Off" time can come on gradually or suddenly and unexpectedly. These resources will help you understand how to identify your "Off" time and associated symptoms, as well as share lifestyle tips and medication options to minimize "Off" time.

Downloadable Documents | Online Articles | Podcasts & Webinars | Expert-level Resources

Downloadable Documents

Communicating About OFF Episodes and Dyskinesia With Your Doctor

Published by the American Parkinson Disease Association, 2023

This 16-page booklet can help explain OFF time to you and your care partner and give you information to communicate with your doctor about what you are experiencing, so you can receive optimal care and maintain your best quality of life. It explains what causes OFF periods, how OFF periods can affect you throughout the day and reduce quality of life, what symptoms you may have during OFF periods and how to communicate with your doctor. Also included are treatment options, 

Motor Fluctuations and Parkinson's "Off" Times

Published by the Parkinson's Foundation, 2021

This two-page fact sheet explains why motor and non-motor fluctuations happen, approaches your doctor may take to smooth your response to medications and minimize or avoid fluctuations, dystonia, and freezing, including medications available to treat "Off" episodes.

Wearing Off and Involuntary Movements in Parkinson's

Published by the Parkinson's UK, October 2022

This 12-page booklet describes the different movement problems that can happen after using levodopa for several years. It explains what might cause them and how they can be controlled, beginning with ON/OFF periods and whether these are the same as 'freezing', what causes motor fluctuations and involuntary movements, and how you can manage them.

Online Articles

How to Communicate What it Means to be OFF

Published by the Davis Phinney Foundation, January 22, 2019

This article aims to provide people with Parkinson’s, care partners, and healthcare providers a common language to define OFF times and suggests how these interested parties can improve communication about OFF times.

How to Understand and Manage OFF Times as a Parkinson's Care Partner

Published by the Davis Phinney Foundation, November 18, 2020

Personal testimonies from Parkinson's care partners offer readers suggestions for how to help a loved one with PD to manage medications to minimize OFF times, exercise and move about safely, cope with frustrations, 

"Off" Time in Parkinson's Disease

Published by the Michael J. Fox Foundation

This is the Fox Foundation's main page about "Off" time and includes not only overview information, but links a webinar, an Ask the MD video, podcast, and blog posts on the topic.

The Science of Parkinson's OFF

Published by the Davis Phinney Foundation, November 16, 2020

OFF periods occur when your medication isn’t working optimally, and your motor and non-motor symptoms return. This article aims to help readers understand the scientific causes of OFF times to help you minimize it in your daily life. Discussed is levodopa's path through the digestive tract and through the blood-brain barrier, the role of protein, constipation, PD progression in affecting OFF times, and more.

Six Tips for Managing Parkinson's "Off Time"

Published by Parkinson's Disease Net, September 5, 2020

This three-minute read includes statistics about the prevalence of OFF times in those with PD, how many hours people report OFF periods in a day, but that 43% of people experiencing OFF times do nothing to manage or prevent these episodes. It then offers tips for reducing OFF times.

You Don't Have to Have OFF Times with Parkinson's

Published by the Davis Phinney Foundation, June 11, 2021

OFF times look different for everyone. Learn the four types of OFF that people with Parkinson’s experience, how to determine if you're ON or OFF, how to talk with your doctor about ON/OFF periods, how exercise, nutrition, and GI health can help minimize OFF times, and how continuous dopaminergic stimulation can help prevent or minimize OFF times.

Podcasts & Webinars

Ask the MD: 'Off' Time in Parkinson's Disease

By the Michael J. Fox Foundation, November 8, 2017

In this five-minute video, movement disorders specialist Rachel Dolhun, MD, talks about motor fluctuations, or "Off" times, how and when they can happen, how they can be managed with lifestyle changes, medication adjustments, rescue levodopa, or DBS, and ongoing treatment research.

Managing Motor Symptoms During OFF Times in Parkinson's

By the Davis Phinney Foundation, July 7, 2022

A panel including a person with Parkinson's, an occupational therapist, and a movement disorder specialist discuss for 40-minutes how to manage motor symptoms when your medication has worn OFF. 

OFF Time in Parkinson's: Your Top 20 Questions Answered

By the Davis Phinney Foundation, September 3, 2021

In this 55-minute webinar, movement disorders specialist Yasar Torres-Yaghi, MD, answers questions about OFF time in Parkinson's including symptoms, medications, deep brain stimulation and more.

Parkinson’s “Off” Time: What It Looks Like, and How to Manage It

By the Michael J. Fox Foundation, September 22, 2021

In this 42-minute podcast, experts discuss “off” periods — those times when medication can wear off between doses, or are not working optimally, and symptoms can return. This explores how people experience “off” differently and the steps you can take to manage “off” time, including how you can communicate with doctors and care partners about what you’re experiencing and ongoing research to decrease or treat these episodes. 

Too Much or Not Enough: Dyskinesia and "Off" Time in Parkinson's

By the Michael J. Fox Foundation, September 16, 2021

In this one-hour webinar, expert panelists discuss common Parkinson’s issues — “off” time and dyskinesia — and how to treat them. “Off” time is when symptoms return between medication doses. Dyskinesia is uncontrolled, involuntary movement. Speakers cover tips for managing these problems and the latest research.

Treatment of OFF Time in Parkinson Disease

By Neurology Live, October 4, 2023

Episode 3 of the 5-part series, "Minimizing Variations in Patient’s Experience with Levodopa Therapy in Parkinson's Disease." In this two-minute video Robert Hauser, MD, MBA, discusses when it is appropriate to consider more than carbidopa/levodopa to minimize OFF Time in PD.
Links to Episode 2, "Predictability of Dyskinesia and OFF Episodes in Parkinson Disease" and Episode 4, "Amantadine Extended Release for the Management of Dyskinesia and OFF Episodes" are easily available.

Expert-Level Resources

Clinical Use of On-Demand Therapies for Patients with Parkinson’s Disease and OFF Periods

By Rajesh Pahwa Published in Neuropsychiatric Disease and Treatment; 23 May 2023, volume 12, pages 1033-1049 (2023)

On-demand therapies for Parkinson’s disease (PD) provide rapid, reliable relief for patients experiencing OFF periods; however, practical guidelines on the use of these therapies are not generally available. This paper reviews the use of on-demand treatments. The conclusion states, "Given the availability of new on-demand treatments (injectable apomorphine, sublingual apomorphine, and inhaled LD), fast-acting therapies that bypass the GI tract, it is time to reevaluate when these therapies should be used. As they are safe and effective for OFF periods, and due to the marked negative impact of the OFF periods, we need to consider using them earlier when patients have motor fluctuations."

The Experience of OFF Periods in Parkinson’s Disease: Descriptions, Triggers, and Alleviating Factors

By Nbaa Masood and Joohi Jimenez-Shahed. Published in Neuropsychiatric Disease and Treatment; 2023; 19: 247–266.

This review focuses on effective management of motor symptoms related to OFF periods, including emerging strategies. Unmet clinical needs are discussed, including non-motor symptoms, targeted molecular therapies and disease modifying therapy. While levodopa has been the cornerstone of PD treatment, adding or switching to different therapeutic strategies is required to mitigate the effects of MF.

The Experience of OFF Periods in Parkinson’s Disease: Descriptions, Triggers, and Alleviating Factors

By Sneha Mantri, MD, MS, Published in the Journal of Patient-Centered Research and Reviews; 2021 Summer; 8(3): 232–238.

Participants in the longitudinal Fox Insight study who endorsed OFF periods were invited to complete a survey consisting of both multiple-choice and free-text responses in order to assess the lived experience of OFF periods for people with Parkinson’s disease. Although OFF periods are common, the individual experiences of OFF vary.

Last updated January 2024 by Stanford Parkinson's Community Outreach