Multiple System Atrophy (MSA)

Multiple System Atrophy is a rare neurological disorder.  It falls under the atypical parkinsonism umbrella.  It is the third most common of the four atypical parkinsonism disorders. Older terms for MSA include Shy Drager Syndrome, Olivopontocerebellar Atrophy, and Striatonigral Degeneration.

MSA Symptoms

MSA is divided into two types. In the United States, MSA-P is more common. Symptoms vary based on the two types. They are:

  • MSA-Parkinsonism (MSA-P): where parkinsonism symptoms are predominant
  • MSA-Cerebellar (MSA-C): where cerebellar symptoms are predominant

Parkinsonism features can include bradykinesia (slow movement), rigidity, tremor, and postural instability. Cerebellar features can include gait ataxia (wide, irregular steps), ataxic dysarthria, limb ataxia, and nystagmus (an oculomotor issue).

Other common symptoms can include severe orthostatic hypotension (blood pressure falls within three minutes of standing), urinary incontinence or urinary retention, erectile dysfunction in men, and REM sleep behavior disorder (RBD).

Less-common symptoms can include antecollis (neck is flexed forward such that the chin rests on the chest), dystonia of the face and mouth, stridor, low volume of speech, myoclonus, emotional incontinence (inappropriate laughter or crying), camptocormia (severe forward flexion of the spine), Pisa syndrome (severe lean of the body), and contractures of the hands and feet.

MSA Treatments

MSA treatments are few. All treatments are focused on symptoms. Parkinsonism may be treated by levodopa. (Some with MSA do have a response to this medication for a short period of time.) Orthostatic hypotension may be treated by a variety of medications. Urinary incontinence can be treated with medication, botox injections, catheters, or adult briefs.

Therapy is worth trying: physical therapy, occupational therapy, and speech therapy. In our local support group, we have seen a few people with MSA benefit from two speech therapy programs designed for Parkinon’s Disease — SPEAK OUT! (by the Parkinson Voice Project) and LSVT-LOUD (by LSVT).

Go-To Organizations for MSA Education

A handful of organizations consistently deliver quality information about MSA. Click the link for each organization to review their web sites:

Organization Name Country Focus Web Address
Mission MSA (previously known as the Multiple System Atrophy Coalition) USA Education, awareness, support
Multiple System Atrophy Trust UK Support, education, awareness

MSA Top Resources

Brain Support Network continually reviews most of the resources available on MSA. In our opinion, the most helpful resources for families are listed below. This list is also available in printable PDF.

MSA Symposium

This 4.5-hour event features an autonomic disorder specialist, movement disorder specialist, physical therapist, speech therapist, neuro-palliative care expert, and BSN’s Robin Riddle about brain donation.  A highlight is the panel moderated by BSN’s Candy Welch with 3 caregivers, a woman with MSA-C (who co-leads the local BSN MSA support group), and a man with MSA-P.  This webpage includes recordings, speaker slides, notes, resource list, and an MSA quiz.  –  coming soon

Top Ten Things You Need to Know About Multiple System Atrophy

Two-page document compiled by MSA Awareness from posts to an online MSA-related support group. These are 10 items not normally highlighted in MSA literature.


MSA: Some Answers

This short brochure was published by CurePSP and last updated in 2023.


Your Essential MSA Guidebook

This 27-page booklet outlines how MSA is diagnosed, symptoms,  stages, putting your care team together, and planning for the future.  Produced by Mission MSA.  Last updated April 2024.


Fact Sheets

The Multiple System Atrophy Trust (UK) has 39 fact sheets on topics such as bowel management, continence, fatigue, Parkinson’s medications, monitoring blood pressure, saliva, driving, and useful equipment for hygiene.

> Main page:

Brain Support Network’s MSA blog

Blog posts include tips by those with MSA and caregivers.

> MSA Blog:

Carer’s Guide

This short guide includes a list of things to think about early: practical, physical, and emotional aspects of caring for someone with MSA. Revised March 2022. Written by the Multiple System Atrophy Trust (UK).


Multiple System Atrophy:  What Is It, Causes, Symptoms, and More

This short webpage is for physicians wanting to learn about MSA.  Consider sharing the link and helpful summary image with your primary care physician.

MSA Brain Donation: Confirm Diagnosis, Support Research for a Cure

Brain Support Network’s Robin Riddle speaks on the benefits of brain donation for MSA.

> May 2024 (10 min): coming soon

> March 2021 (50 min):

Recent MSA Patient/Family Conferences

There were many terrific speakers at the MSA Coalition’s all-day events. (The Coalition is now known as Mission MSA.)  Recent unedited conference recordings:

> 2022 (50 videos):

> 2021 Living with MSA (5 videos):

> 2021 Medical Panels (4 videos):

> 2021 Research Panels (4 videos):

Treating Progressive Supranuclear Palsy (PSP), Multiple System Atrophy (MSA), and Corticobasal Degeneration (CBD) – What can be done?

Movement disorder specialist Dr. Brent Bluett describes the symptomatic treatments possible for MSA that can improve quality of life. His messages:  Each treatment individually may be minor, but in sum they can make a significant difference. And, there is always hope! The recording from this February 2019 webinar, co-hosted by Brain Support Network and Stanford University, remains one of our most-viewed programs.

> Detailed notes:

>  Recording:

MSA and Cognition

Movement disorder specialist Dr. Kathleen Poston describes cognitive aspects of MSA.  This November 2018 webinar was co-hosted by Stanford University and Brain Support Network.

> Detailed notes:

> Recording:

Orthostatic Hypotension (OH) in Parkinson’s Disease (PD), Multiple System Atrophy (MSA), and Lewy Body Dementia (LBD)

Movement disorder specialist Dr. Veronica Santini describes the symptoms of OH, conservative interventions, and medications. This September 2017 webinar was co-hosted by Stanford University and Brain Support Network.

> Detailed notes:

> Recording:

Evaluating and Treating Urinary Issues in Parkinson’s Disease (PD), Multiple System Atrophy (MSA), and Other Atypical Parkinsonism Disorders

Urologist Dr. Ekene Enemchukwu focuses on urinary incontinence, overactive bladder, urinary retention, nocturia, and other urinary issues. This August 2019 webinar was co-hosted by Stanford University and Brain Support Network.

> Detailed notes:

> Recording:


Top Resources – Oldies but Goodies

These are all older resources that we hate to give up on because they are well-done summaries of MSA.  However, because of the publication dates, there may be outdated information.

A Guide to Multiple System Atrophy

This 36-page guide, last revised in November 2015, was written by the Multiple System Atrophy Trust in the UK.  It offers a short description of MSA and details on treatment and management of symptoms.


MSA: NINDS Pamphlet and Fact Sheet

These were written by the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health (NIH), and revised in November 2014.

> Pamphlet:

> Webpage:

> En Español:

MSA: What You Need to Know

This 53-page document is an in-depth look at treatment of common symptoms in MSA.  Produced by the MSA Coalition.  Last updated in April 2019.

> MSA-Coalition_WhatYouNeedToKnow_Apr2019.pdf

Less-Recent MSA Patient/Family Conferences

There have been many terrific speakers at the MSA Coalition’s all-day events. Note in particular Dr. Allyson Mayeux’s keynote address in October 2016 about her brother Hal’s MSA journey, ending in brain donation.  Unedited conference recordings are here:

MSA NJ Patient/Family Conference

There have been many terrific speakers at MSA NJ’s all-day conferences.  The most recent recording on their website is from 2019.  Note in particular the talks on practical methods and “toolbox kit.”

> 2019:

Treatment of and Research on Multiple System Atrophy

Movement disorder specialist Dr. Kathleen Poston gave an indepth presentation on MSA as part of an atypical parkinsonism symposium organized by Stanford University and Brain Support Network in October 2012.

> Recording:

Exploring Diagnosis, Management and Best Practice Interventions in Relation to PSP, MSA, and CBD

One of the world’s top researchers of MSA, Dr. David Williams presents on several disorders at a November 2009 conference for allied health professionals (RNs, PTs, OTs, STs, social workers, etc) in Melbourne, Australia. His presentations are divided into a series of 10-minute online video segments. The MSA presentation…

> Starts here:
> Continues until timestamp 2:30:


MSA Diagnostic Criteria

The diagnostic criteria for MSA presented here reflect those reported by Gilman, et al, Second Consensus statement on the diagnosis of multiple system atrophy, Neurology. 2008 Aug 26;71(9):670-6.

Definitive Diagnosis of MSA

  • Brain autopsy required

Probable Diagnosis of MSA (“Table 1”)

A sporadic, progressive, adult (>30 years) onset disease characterized by:

Probable Diagnosis of MSA-P Probable Diagnosis of MSA-C
Autonomic failure involving urinary incontinence (inability to control the release of urine from the bladder, with erectile dysfunction in males) or
An orthostatic decrease of blood pressure within 3 min of standing by at least 30 mm Hg systolic or 15 mm Hg diastolic.
Poorly levodopa-responsive parkinsonism (bradykinesia with rigidity, tremor, or
postural instability)
Cerebellar syndrome (gait ataxia with cerebellar dysarthria, limb ataxia, or
cerebellar oculomotor dysfunction)

Possible Diagnosis of MSA (“Table 2”)

Note that “Possible Diagnosis” requires that at least one additional symptom from the list of “Additional Symptoms of Possible MSA”.  These are listed in “Table 3”.  A sporadic, progressive, adult (>30 years) onset disease characterized by:

Possible Diagnosis of MSA-P Possible Diagnosis of MSA-C

  • Bradykinesia with rigidity
  • Tremor, or
  • Postural instability)
A cerebellar syndrome:

  • Gait ataxia with cerebellar dysarthria,
  • Limb ataxia, or
  • Cerebellar oculomotor dysfunction
At least one feature suggesting autonomic dysfunction (otherwise unexplained urinary urgency, frequency or incomplete bladder emptying, erectile dysfunction in males, or significant orthostatic blood pressure decline that does not meet the level required in probable MSA)
At least one of the additional features shown in Table 3

Additional symptoms of possible MSA (“Table 3”)

Additional symptoms of possible MSA-P Additional symptoms of possible MSA-C
  • Babinski sign with hyperreflexia
  • Stridor


  • Rapidly progressive parkinsonism
  • Poor response to levodopa
  • Postural instability within 3 y of motor onset
  • Gait ataxia, cerebellar dysarthria, limb ataxia, or cerebellar oculomotor dysfunction
  • Dysphagia within 5 y of motor onset
  • Atrophy on MRI of putamen, middle cerebellar peduncle, pons, or cerebellum
  • Hypometabolism on FDG-PET in putamen, brainstem, or cerebellum
  • Parkinsonism (bradykinesia and rigidity)
  • Atrophy on MRI of putamen, middle cerebellar peduncle, or pons
  • Hypometabolism on FDG-PET in putamen
  • Presynaptic nigrostriatal dopaminergic denervation on SPECT or PET

Symptoms supporting a diagnosis of MSA (“Table 4”)

  • Orofacial dystonia
  • Disproportionate antecollis
  • Camptocormia (severe anterior flexion of the spine) and/or Pisa syndrome (severe lateral flexion of the spine)
  • Contractures of hands or feet
  • Inspiratory sighs
  • Severe dysphonia
  • Severe dysarthria
  • New or increased snoring
  • Cold hands and feet
  • Pathologic laughter or crying
  • Jerky, myoclonic postural/action tremor

Cautionary Symptoms not supporting a diagnosis of MSA (“Table 4”)

  • Classic pill-rolling rest tremor
  • Clinically significant neuropathy
  • Hallucinations not induced by drugs
  • Onset after age 75 years
  • Family history of ataxia or parkinsonism
  • Dementia (on DSM-IV)
  • White matter lesions suggesting multiple sclerosis