Tremor, Shakes & Everything in Between: Tackling Parkinson's Motor Symptoms

Parkinson’s disease (PD) can make it difficult to move when you want to, in the way that you want to and equally hard to stay still. From shaking and stiffness to muscle cramping and difficulty walking, challenges with movement (motor) symptoms can affect all aspects of daily life when it comes to Parkinson’s. Discover how exercise, medications and other strategies can help you move easier.

The following article is based on a Parkinson’s Foundation Expert Briefing exploring motor symptoms in PD, hosted by movement disorders specialist Pablo Coss, MD, Neurology Residency and Movement Disorders Fellowship at University of Texas Health Science Center at San Antonio, part of the Parkinson’s Foundation Global Care Network.

Key Parkinson’s Traits

Parkinson’s is called a movement disorder because it impacts how a person moves. While symptoms usually develop slowly over time, Parkinson’s is progressive — needs can change as PD advances through stages. A person’s history, symptoms and a physical exam are used to make a diagnosis.

To consider a diagnosis of Parkinson’s, slowness of movement (bradykinesia) must be present along with either:

• Resting tremor, rhythmic, involuntary movement that tends to happen when the affected part of the body is at rest. This tends to affect one side of the body in early PD.

• Stiffness (rigidity) resistance to movement caused by involuntary muscle activation at rest.

• Balance issues (postural instability) that lead to stumbles and falls. 

Dopamine and Movement

Although scientists are still working to understand the causes of Parkinson’s, we know that the disease is a progressive brain disorder that damages dopamine-producing neurons. Dopamine is a chemical messenger that regulates mood and helps the body move smoothly.

Movement Changes in PD

Dopamine loss in an area of the brain called substantia nigra and other chemical changes in Parkinson’s interfere with brain signals, causing many non-movement symptoms —including emotional changes, gut issues and fatigue — and impact movement in different ways, including:

• Bradykinesia — a slowness of movement that can affect the whole body, causing fatigue and difficulty walking or completing everyday tasks. It can also cause: 

  • Facial masking, stiffness in the face muscles that makes it difficult to express emotions.

  • Challenges with hand movements, making it harder to do things like ripping a bag open, unscrewing a cap or writing. Micrographia — small, cramped handwriting seen frequently in early PD — is strongly connected to slowness of movement.

  • Difficulty rising to stand while sitting.

• Tremor. People with Parkinson’s often have a resting tremor in one hand or arm, but it can also affect the legs, jaw or face. Tremor in the hand is often described as “pill-rolling” — the thumb moves with other fingers as if it were rolling a pill between them.

Action tremor, another PD symptom, happens when the affected area of the body is moving or trying to do a task like writing or drinking from a cup. Many people with Parkinson's experience a combination of resting and action tremor.

• Rigidity, stiffness that is sometimes described as “lead-pipe” rigidity — the body’s resistance to movement during a physical exam (when relaxed) can be so strong that it can feel as if the examiner is trying to bend a heavy metal pipe. Rigidity can lead to:

  • painful aches and difficulty sleeping

  • reduced arm swing when walking

  • facial stiffness

• Dystonia, painful, repetitive muscle cramping and twisting common in Parkinson’s, can:

  • make the fingers clench up or hold an abnormal position

  • cause the ankle to turn in and the toes to curl

  • impact the face and eyes, making it difficult for some people to open their eyes voluntarily

  • be accompanied by a jerky tremor that can overlap with other forms of PD tremor

• Hypophonia (speech problems can include soft or slurred speech, difficulty with articulation, reduced speaking volume or monotone voice, which — coupled with facial stiffness — can make emotional expression challenging. Hypophonia can also cause shallow breaths, stuttering or rushed speech.

• Parkinsonian gait — PD changes the way a person walks, causing small, shuffling steps, stooped shoulders, reduced arm swing or difficulty lifting the feet.

These balance and gait challenges — along with short, rapid steps that tend to speed up (festination), backward leaning and imbalance — increase the risk for falls and injuries, as does freezing of gait: a temporary but dangerous feeling of the feet being stuck to the floor. Crowded areas, doorways and thresholds can trigger freezing.

Increasing Dopamine: Exercise & Medications

Because dopamine loss drives Parkinson’s movement symptoms, increasing dopamine is the most effective way to manage them — and exercise is one of the simplest ways to help boost dopamine and slow PD progression.

Exercise can ease PD movement symptoms and improve strength and balance. Finding an exercise you enjoy can give you the motivation to keep moving. Our PD Health @ Home Fitness Fridays workouts, a collection of Parkinson’s-tailored fitness videos, can help you get active at home.

Levodopa is the most effective treatment for Parkinson’s. Brain cells metabolize levodopa to dopamine. It is most often combined with carbidopa — this allows more levodopa to enter the brain without being metabolized first by the gut (where it can cause nausea.)

To maintain the necessary dopamine levels to help the body function optimally, it is vital to take medications exactly as prescribed. It is common for your doctor to adjust dosing as Parkinson’s progresses, to manage changing symptoms.

There are many levodopa formulations, including:

• Immediate release (Sinemet IR), often prescribed in three or more doses per day.

• Controlled release (Sinemet CR), also prescribed in three or more doses per day. 

• Newer, extended-release formulations (Rytary or Crexont) may offer quicker and longer-lasting effects. These might be prescribed two to four times per day.

• Pump therapies deliver a steady supply of medication:

  • Vyalev delivers foscarbidopa/foslevodopa through a wearable pump and a needle inserted under the skin.

  • Duopa provides continuous carbidopa/levodopa gel through a surgically inserted tube.

• Inhaled levodopa (Inbrija) is used as needed to treat the return of symptoms between regular carbidopa/levodopa doses, from four to five times a day

Levodopa side effects can include nausea, constipation, dizziness, low blood pressure, drowsiness, hallucinations, or behavior changes, such as hypersexuality (impulse control disorder.)

Over time, some Parkinson’s medications can also cause erratic movements (dyskinesia) — including writhing, rocking, wriggling and dancing. This can often happen after taking a dose when levodopa reaches its maximum effectiveness in the body.

Parkinson’s Progression, Motor Fluctuations & Advanced Treatments

Though Parkinson’s impacts everyone differently, as Parkinson’s advances, for many people, the return or worsening of symptoms (motor fluctuations or “off” time) between doses of medications can occur more frequently. This may lead to increased dyskinesia, imbalance, or falls or the need for assistive devices — tools designed to improve daily living.

Talk to your doctor about any concerns. He or she can work with you to adjust your medication or explore advanced treatments.

Medications used to improve the effect and duration of levodopa include:

• COMT inhibitors

• MAO-B inhibitors, which can rarely cause serotonin syndrome

• Dopamine agonists, which can cause sleep attacks or impulse control disorders

• Anticholinergics

• Adenosine A2A antagonists

• NMDA receptor antagonist (amantadine) — often used to suppress dyskinesia

These medications can cause various side effects, including nausea, dyskinesia, headache, low blood pressure, dizziness, urine retention or discoloration, sleep problems or insomnia.

Surgery can be an option for movement symptoms in advanced Parkinson’s. Options can include:

• Deep brain stimulation (DBS), surgery that helps control Parkinson’s movement symptoms, motor fluctuations and reduce medication doses.

• Focused ultrasound, a newer, incisionless procedure guided by magnetic resonance imaging (MRI) that uses energy to shut down abnormal signaling an area of the brain connected to tremor.

Learn More

To learn more about managing movement symptoms in Parkinson’s, explore our resources below, or call our free Helpline at 1-800-4PD-INFO (1-800-473-4636):

• Use It or Lose It: It’s Never Too Late to Get Moving in Parkinson’s

• Fact Sheet: Medications for Movement Symptoms

• Advanced Treatment Options: A Guide to Deep Brain Stimulation, Pump Medications & Focused Ultrasound