Understanding Multiple System Atrophy: Symptoms, Causes, and Care
Understanding Multiple System Atrophy (MSA) - a comprehensive guide to its symptoms, types, causes, and how it is diagnosed and managed.
Written by Dr. Shaik Abdul Kalam
Reviewed by Dr. D Bhanu Prakash MBBS, AFIH, Advanced certificate in critical care medicine, Fellowship in critical care medicine
Last updated on 16th Sep, 2025
Multiple System Atrophy (MSA) is a rare and progressive neurological disorder that profoundly affects the body's involuntary (autonomic) functions, as well as movement and balance. Often mistaken for Parkinson's disease in its early stages, MSA is a distinct and more aggressive condition. For patients and families, receiving a diagnosis can be a confusing and overwhelming experience, marked by a search for answers and effective management strategies. This article aims to demystify multiple system atrophy, providing a comprehensive overview of its symptoms, types, causes, and the available care options. We will explore the key differences from other conditions, outline the diagnostic process, and discuss how to build a supportive care plan to manage this challenging disorder. Understanding MSA is the first step toward navigating its complexities with greater clarity and confidence.
What is Multiple System Atrophy (MSA)?
Multiple System Atrophy is a neurodegenerative disorder, meaning it causes the gradual deterioration of specific nerve cells in the brain and spinal cord. The term "multiple system" refers to the fact that it impacts several functional systems within the body, primarily the autonomic nervous system (which controls blood pressure, digestion, bladder function, etc.) and the motor system (which controls movement). The hallmark of MSA is the abnormal accumulation of a protein called alpha-synuclein in certain brain cells, specifically in support cells called oligodendroglia. These deposits, known as glial cytoplasmic inclusions, are toxic and lead to the progressive loss of neuronal function.
How MSA Differs from Parkinson's Disease?
While both MSA and Parkinson's disease are synucleinopathies (diseases involving alpha-synuclein buildup), they are distinct entities. Key differences include:
Rate of Progression: MSA progresses much more rapidly than Parkinson's.
Autonomic Symptoms: Severe autonomic dysfunction like a significant drop in blood pressure upon standing (orthostatic hypotension) and urinary incontinence appear early and are far more prominent in MSA.
Response to Medication: Patients with Parkinson's typically respond well to levodopa medication for many years. Most MSA patients have a poor or short-lived response to levodopa.
Specific Motor Symptoms: Certain features, like severe problems with coordination (ataxia) or a strained, quivering voice, are more characteristic of MSA.
The Two Main Types of MSA
MSA is categorized into two primary types based on the most dominant motor symptoms at the time of diagnosis.
MSA with Cerebellar Ataxia (MSA-C)
This type is characterized by ataxia, which is a loss of coordination and balance. The cerebellum, the part of the brain responsible for coordinating voluntary movements, is primarily affected. Symptoms include:
A wide-based, unsteady gait (walking pattern)
Difficulty with fine motor skills (like buttoning a shirt)
Slurred speech (dysarthria)
Abnormal eye movements (nystagmus)
MSA with Parkinsonism (MSA-P)
Formerly known as Striatonigral Degeneration, this type is dominated by parkinsonian symptoms, which are similar to those seen in Parkinson's disease. These include:
Slowness of movement (bradykinesia)
Stiffness and rigidity in muscles
Tremors (though less prominent and often irregular compared to Parkinson's)
Postural instability, leading to falls
It's important to note that as the disease progresses, individuals often develop a combination of symptoms from both categories, and autonomic dysfunction is a severe and universal feature of both types.
Recognising the Symptoms of MSA
MSA symptoms are wide-ranging and worsen over time. They are broadly divided into motor symptoms and autonomic symptoms.
Motor Symptoms (Movement-Related)
Parkinsonism: Slowness, stiffness, and shuffling walk.
Ataxia: Poor coordination and unsteady balance.
Abnormal Posture: May develop a stooped posture or abnormal neck flexion.
Speech and Swallowing Difficulties: Speech may become slow, slurred, or quiet. Swallowing can become difficult (dysphagia) later in the disease course.
Autonomic Dysfunction: The Hallmark of MSA
This is what primarily distinguishes MSA from other movement disorders. The autonomic nervous system controls involuntary bodily functions.
Orthostatic Hypotension
This is a sudden drop in blood pressure upon standing up, leading to dizziness, lightheadedness, blurry vision, or fainting. It is one of the most common and disabling autonomic dysfunction symptoms.
Urinary and Bowel Dysfunction
This can include an urgent need to urinate, difficulty emptying the bladder completely, frequent urinary tract infections, incontinence, and severe constipation.
Other Autonomic Issues
Erectile Dysfunction: Often one of the first symptoms in men.
Temperature Regulation Problems: Reduced ability to sweat, leading to overheating.
Sleep Disorders: Violent dreams, insomnia, or acting out dreams (REM sleep behavior disorder), which can precede other symptoms by years.
Breathing Issues: Noisy breathing, especially at night, or episodes of gasping or sighing.
What Causes Multiple System Atrophy?
The exact cause of multiple system atrophy remains unknown. It is not contagious, and for the vast majority of cases, it is not inherited. The current scientific consensus points to a combination of genetic vulnerability and unknown environmental triggers that kickstart the disease process.
The Role of Alpha-Synuclein Protein
The central mechanism of MSA involves the misfolding and clumping of the alpha-synuclein protein within the brain's oligodendroglia cells. These clumps, or aggregates, are toxic and cause inflammation and damage, leading to the dysfunction and eventual death of the neurons that these cells support. This progressive loss of neurons in key areas of the brain and spinal cord is responsible for all the symptoms of MSA. Research into why this protein misfolds is ongoing and is the focus of potential future treatments.
How is MSA Diagnosed?
Diagnosing multiple system atrophy is challenging due to its similarity to other conditions like Parkinson's disease. There is no single definitive test. Diagnosis is primarily clinical, based on medical history, a detailed neurological examination, and the exclusion of other disorders.
The Challenge of Diagnosis and Misdiagnosis
Many patients are initially diagnosed with Parkinson's disease. The diagnosis of MSA is often reconsidered when the patient's symptoms progress rapidly, or when severe autonomic symptoms become apparent without a strong response to Parkinson's medication. A definitive diagnosis can only be confirmed by examining brain tissue posthumously.
Key Diagnostic Tests
To support the clinical diagnosis and rule out other conditions, neurologists may order:
Autonomic Testing: Measures heart rate, blood pressure, and sweating in response to various stimuli.
MRI of the Brain: Can show specific changes, such as shrinkage (atrophy) in certain brain areas like the cerebellum or putamen, or a specific sign called the "hot cross bun" sign in the pons.
Levodopa Challenge Test: A trial of high-dose levodopa to assess if motor symptoms improve.
Urodynamic Studies: To evaluate bladder function.
Sleep Study (Polysomnography): To identify REM sleep behavior disorder.
Given the complexity of these symptoms, consulting a neurologist, preferably a movement disorder specialist, is crucial. If you are seeking a specialist for evaluation, you can consult a doctor online with Apollo24|7 to discuss your symptoms and get a referral.
Treatment and Management of MSA
There is currently no cure for multiple system atrophy, and no treatments to slow its progression. The management approach is focused on alleviating symptoms, maximizing quality of life, and providing supportive care.
Managing Motor Symptoms
Levodopa: A trial is usually given, but only about one-third of MSA patients experience any benefit, and it is often temporary.
Physical, Occupational, and Speech Therapy: Essential for maintaining mobility, adapting the home environment, and addressing speech and swallowing difficulties.
Treating Autonomic Dysfunction
For Orthostatic Hypotension: Increased salt/fluid intake, compression stockings, and medications like fludrocortisone or midodrine.
For Urinary Issues: Medications, intermittent self-catheterization, or specialist consultation with a urologist.
For Constipation: High-fiber diets, laxatives, and stool softeners.
Managing these fluctuating symptoms often requires frequent medication adjustments. For ongoing prescription management and follow-up, booking a physical visit to a doctor with Apollo24|7 ensures consistent and specialized care.
The Importance of Supportive Therapies
A multidisciplinary team is vital. This includes physiotherapists to prevent falls, speech therapists for communication and swallowing strategies, and dietitians to ensure nutritional needs are met, especially if swallowing becomes impaired.
Prognosis and Living with MSA
MSA is a progressive disease with a poor prognosis. The average survival from the onset of symptoms is between 7 to 10 years, though this varies. The most common causes of death are respiratory or cardiac problems. While this reality is difficult, the focus must be on quality of life.
Building a Support System
A strong support system is indispensable. This includes:
Family and Friends: For daily assistance and emotional support.
Professional Caregivers: To help with activities of daily living as the disease advances.
Support Groups: Connecting with other MSA patients and caregivers through organizations like The MSA Coalition (US) or MSA Trust (UK) can provide invaluable emotional support, practical advice, and a sense of community.
Consult Top Specialists
Conclusion
Receiving a diagnosis of multiple system atrophy is life-altering. The journey ahead is undeniably challenging, marked by progressive physical decline. However, understanding the nature of the disease empowers patients and caregivers to become active participants in care. While research for a cure continues, current management strategies focus on providing dignity, comfort, and the best possible quality of life. Early and accurate diagnosis, a proactive and comprehensive care plan, and a robust support system are the cornerstones of navigating MSA. Remember, you are not alone—leveraging the expertise of medical professionals and the shared experiences of the MSA community can provide crucial strength and guidance. If you or a loved one are experiencing a combination of these symptoms, especially with early autonomic issues, it is critical to seek a neurological evaluation promptly.
Consult Top Specialists
Consult Top Specialists
Dr. Aditendraditya Singh Bhati
Neurosurgeon
18 Years • MBBS(2004), DNB Neurosurgery(2014); MNAMS; Fellow Neuroendoscopy
Delhi
Apollo Hospitals Indraprastha, Delhi
(100+ Patients)
Dr. Ganeshgouda Majigoudra
Neurologist
10 Years • MBBS, MD ( GENERAL MEDICINE) DM (NEUROLOGY)
Bengaluru
Apollo Clinic, JP nagar, Bengaluru
Dr. E Prabhakar Sastry
General Physician/ Internal Medicine Specialist
40 Years • MD(Internal Medicine)
Manikonda Jagir
Apollo Clinic, Manikonda, Manikonda Jagir
(125+ Patients)
Dr Rajashekar Mummadi
Neurologist
3 Years • MBBS, DNB General Medicine, DRNB Neurology
Hyderabad
Dr Ram's Neuro Clinic, Hyderabad
Dr S Selvin
Neurologist
10 Years • MBBS, MD, DM (Neurology), FINR fellowhsip in Interventional Neuro Radiology
Chennai
Apollo Speciality Hospitals Vanagaram, Chennai