Multiple system atrophy (MSA) is a rare, adult-onset, neurological disease that impacts movement, coordination and the autonomic nervous system. MSA is commonly referred to as an atypical parkinsonism because of its overlap with certain symptoms of Parkinson’s disease.
MSA is considered rare, affecting 2-5 individuals per 100,000, with about 13,000 cases in the United States. These numbers are likely underestimates due to frequent misdiagnosis of Parkinson’s disease or frontotemporal dementia.
In comparison, about 1 million people in the U.S. have Parkinson’s disease, and about 7 million have Alzheimer’s disease.
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MSA affects multiple areas of the brain that primarily affect movement and autonomic system. Common symptoms of MSA include: To diagnose MSA, a neurologist will gather a person’s medical history, including neurological symptoms, and will perform a physical examination. At this time, there is no specific test of body fluids nor imaging test of the brain that makes the diagnosis. A brain MRI can show changes in parts of the brain that would support the MSA diagnosis, but because changes in the brain do not always show up on an MRI, particularly in the first few years of symptoms, brain MRI cannot be relied upon as the sole diagnostic test. Your neurologist may decide to use other tests, such as a DaTscan, positron emission tomography (PET) scan, or autonomic nervous system testing, to help support the diagnosis of MSA. However, like the brain MRI, these tests can only support the diagnosis but are not sensitive enough nor specific enough to make the diagnosis alone. Given the rarity of the disease, many people with MSA face a long and confusing diagnosis journey. It is common Most brain disorders affect more than one set of circuits or areas of the brain, so why does MSA deserve the term “multiple”? It’s because it was once three different diseases. The cerebellar type of MSA (MSA-C) used to be known as olivopontocerebellar atrophy (OPCA); the parkinsonian subtype (MSA-P) was called striatonigral degeneration (SND); and MSA with disproportionate autonomic symptoms was called Shy-Drager syndrome. By 1989, scientists discovered that the abnormalities under the microscope in the three conditions were identical except for their locations, which overlapped significantly. They coined the term “multiple system atrophy” as a tribute to the historical notion of three disorders in one. Still, sometimes we still hear these older names used. Dementia, or severe memory or cognitive decline, is very unusual in MSA. However, people with MSA may develop milder signs of mental changes, typically after living with the disease for several years. People with MSA can develop difficulty in the aspect of thinking called executive function. This aspect is what allows us to organize information by categories, understand abstractions and instructions, create and follow a plan, and inhibit inappropriate actions and behaviors. Common mental changes that people with MSA may notice include slowed thinking, difficulty with keeping their attention on a task, and difficulty with multitasking. Occasionally, people with MSA may also experience inappropriate or unintentional laughter or crying, a symptom called pseudobulbar affect. These mental changes rarely become functionally limiting for people living with MSA. MSA, like Parkinson's disease, is a movement disorder and features problems with movement and coordination. People with MSA tend to experience issues with balance, stiffness, smaller and slower movements and issues with the autonomic nervous system. Myoclonus: Sudden, rapid jerks of a limb or of the trunk. This can occur at rest or in reaction to an external stimulus such as a physical touch. While this symptom can be annoying, it rarely interferes with normal movement and can be treated with medication. Parkinsonism: Slowness, smallness, and stiffness of movement, as well as tremor and changes in gait and balance. Other common problems related to movement in parkinsonism include reduced arm swing with walking, small or cramped handwriting, soft voice and reduced facial expression. Tremor in MSA tends to be worse when limbs are in use, whereas tremor in Parkinson’s disease tends to be worse when at rest. Cerebellar ataxia: Problems in the cerebellum (located at the back of the brain) can cause a staggering, drunken-like gait, imbalance, uncoordinated movements, difficulty reaching for things with the arms, sloppy handwriting and slurred speech. As a reminder, no person with MSA will experience all of these symptoms, and each person will have their own severity of symptoms. There are many symptom management options and adaptive techniques for these symptoms, even as the disease progresses. People with MSA may develop difficulty with speaking. This difficulty can manifest as soft speech or slurred speech. Swallowing can also become difficult and may require people to alter the consistency of their food or to take special precautions while eating. For these reasons, your doctor may recommend that you participate in regular evaluations and treatment with a speech-language pathologist. In some cases, if swallowing becomes very difficult, people may choose to get a special tube placed into the stomach for feeding. People with MSA often develop problems with their autonomic nervous system. The autonomic nervous system takes care of things you don’t have to think about, such as blood pressure, heart rate, sweating, emptying the bladder or bowels and sexual function. Common autonomic nervous system symptoms in MSA include: These ANS symptoms will be treated as individual symptoms on an as needed basis. One or more limbs can develop uncontrolled muscle contractions that lead to abnormal, fixed postures in a limb or in the neck, which is called dystonia. These issues can be prevented to some degree with stretching exercises and physical and occupational therapy. Dystonia can be treated in some cases using oral medications or with botulinum toxin (Botox) injections into the affected limb. Some people with MSA hold their head bent forward to an extreme degree, a condition called antecollis. This problem may be improved with Botox injected into the neck muscles. Jaw clenching or forced eye closure occur and can also be treated with medication or Botox injections. Botox injections should only be performed by an experienced neurologist to minimize risks and side effects. Unfortunately, MSA is progressive. This means that over time, people with MSA will notice increasing severity of their symptoms and/or onset of new symptoms. Not everyone experiences all of the symptoms of MSA, and the appearance and progression of these symptoms vary greatly among individuals. Research has shown that someone with MSA lives about eight to ten years after the onset of symptoms, on average. The most common complications in MSA are infections, particularly pneumonia and urinary tract infections. Abnormal breathing, particularly at night, along with severe blood pressure fluctuations, blood clots, and falls are other common and potentially serious complications in MSA. Your doctor may recommend regular examinations of your swallowing function to ensure that food is not entering the lung spaces and causing pneumonia, evaluations by a urologist to test your urinary function, sleep studies to test your nighttime breathing, adaptive equipment to improve your safety with ambulation, and other preventative measures. Quality of life is enhanced by attentive care, maintaining general health, and perhaps most important, by an optimistic and hopeful attitude of the patient and family. We recognize this information is scary and overwhelming to learn and to think about. It can be helpful to talk this through with your medical team and your family, including planning for the future and your wishes for quality of life. CurePSP and the rest of your support system are here to help.
to go through a number of tests, specialists, and diagnoses. It is our hope that better awareness of MSA, especially within the medical community, will lead to earlier and more accurate diagnosis.
Building a support team is foundational to the quality of life for the person diagnosed and their loved ones. Your support team may consist of your family, friends, support group, religious community, healthcare team and anyone else who cares about you. Download: Supporting Someone Diagnosed Find the right medical team. Professionals that can help with symptom management, care planning and education may include: Consider other care options. There are many options to help people with MSA get the care they need. People find huge benefits to hiring help to provide in-home care, utilizing community-based services such as adult day centers and choosing between many types of long-term care facilities. These services can provide additional layers of support, including companionship or hands-on help for the person with MSA and assistance and respite for the family. Professional In-Home Care: Where to Start and What to Ask Understanding Professional Long-Term Care Connect with others who understand the experience. CurePSP has over 15 virtual national and international support groups, a vast network of regional support groups and music therapy and chair yoga sessions. Learn more about these great opportunities for community connection. In addition, CurePSP has Peer Supporters who are volunteers that have a direct connection to PSP, CBD or MSA and offer one-on-one emotional and practical support to individuals in the disease journey. Peer supporters can connect with people through phone, email or in-person meet-ups. Click here to find a Peer Supporter near you or to volunteer as a Peer Supporter. No matter how you find support, please remember that you do not have to navigate the PSP journey alone. Connect with CurePSP at info@curepsp.org to learn more about resources and support. People with MSA and related diagnoses can greatly benefit from rehabilitation therapies. Rehabilitation therapies are individualized interventions to improve or maintain quality of life. For people with MSA, physical therapy (PT), occupational therapy (OT) and speech-language therapy often help people maintain or prolong their physical abilities as the disease progresses. A physical therapist (PT) helps people with movement symptoms they are experiencing. This typically looks like going through exercises during appointments that can help strengthen or correct movements that are important for balance and coordination and then continuing them at home. People with MSA should begin to see a physical therapist when they notice changes in balance or are having more difficulty getting around and completing daily actives. Reasons to see a physical therapist: An occupational therapist (OT) helps people continue doing tasks and activities that prolong independence and help maintain a sense of joy and meaning in their lives. Reasons to see an occupational therapist: A speech-language pathologist (SLP) works with people who are having issues with speech, swallowing and language. Their goals are to improve and prolong communication skills, assess and help adapt to swallowing changes. Reasons to See a Speech-Language Pathologist: When living with a serious and progressive disease, it’s normal to experience sadness, uncertainty and fear about what the future may hold. These are normal emotions to process after receiving a life altering diagnosis — it requires a lot of emotional and physical energy to continually adapt to physical and mental changes! Like all feelings, these emotions are often temporary. However, when these normal emotions regularly interrupt your daily life and prevent you from participating in activities that you previously enjoyed, this could be a sign of a mental health issue. The most common mood symptoms in MSA are apathy and depression. Some people with MSA may experience some anxiety, as well. While these symptoms and be isolating and scary, there are some treatment options to consider. Possible medications for apathy, depression and anxiety for people with MSA: Tricyclic Antidepressants (TCAs) Warning: Low Blood Pressure Warning: A main symptom of MSA is low blood pressure, which can cause dizziness and even fainting. Because of this, people with MSA should monitor their symptoms and work closely with their doctor when being prescribed these medications. If you have low blood pressure, it’s suggested that you drink up to 60-80 ounces (or around 1.5 to 2 liters) of water a day, if you don’t have any contraindication, such as heart and kidney diseases. You may also want to discuss with your physician or neurologist to see if you should increase your salt intake. Many medications could reduce blood pressure. Medications that could do so include antipsychotics, antidepressants, prostate enlargement medication or diuretics. Speak with your physician and neurologist to see if any of these medications could be removed before taking any blood pressure-enhancing medication. Always speak with your neurologist before starting a mood medication. Non-drug methods for improving mood: Urgent mental health support options: At this time, we have no medication to cure MSA or to slow its progression. As research has shown repeatedly that cardiovascular exercise can slow the progression of motor decline in most neurodegenerative conditions, exercise remains a very important piece of disease management for people with MSA. Some symptoms of MSA can be managed successfully with medications for the same symptoms in other conditions. Examples include medications to raise blood pressure, enhance sleep, improve bladder emptying, stimulate the bowel, treat dystonia and spasticity, and treat anxiety or depression. Drugs for Parkinson’s disease that stimulate the brain’s dopamine system, particularly carbidopa-levodopa, can be effective in alleviating some of the parkinsonism symptoms in MSA, though the response is typically not as dramatic or long-lasting as in Parkinson’s disease. Your doctor will work with you closely to try different medications, timing, and dosages to maximize the benefits for your symptoms while also trying to minimize side effects. Physical, occupational, and speech therapy are also important pillars of treatment to address many of the symptoms and challenges faced by people living with MSA, such as speaking, swallow- ing, balance, and daily activity performance. Home safety evaluations performed by trained physical and occupational therapists are extremely useful to help prevent falls and to recommend adaptive equipment such as grab bars, shower chairs, walkers, or wheelchairs. There have been only relatively small case series as examples of people with MSA undergoing deep brain stimulation surgery, or DBS. Only very few people with MSA who received DBS (because they were misdiagnosed as having Parkinson’s disease) had any symptomatic improvement, and in all of those cases, the benefits were very brief. In many cases, people with MSA who underwent DBS noticed worsening of their symptoms after implantation. For these reasons, DBS is not recommended for MSA.
People with MSA may develop some or all of the groups of symptoms listed above. Currently there are two recognized subtypes of MSA, defined by their predominant symptoms. One is the parkinsonian subtype (MSA-P). People with this type of MSA have more parkinsonism symptoms, meaning slow and small movements, tremor, and shuffling gait. Many people with this subtype may be misdiagnosed with Parkinson’s disease initially. The other subtype of MSA is the cerebellar subtype (MSA-C). This subtype is diagnosed when someone has a predominance of cerebellar ataxia symptoms, meaning balance and coordination trouble. People with this subtype may be misdiagnosed with other forms of cerebellar ataxia initially, particularly genetic or inflammatory conditions. Typically, people living with MSA over time will develop at least some degree of symptoms in both subtypes, though one will often remain more prominent. Both of these subtypes share the same pathology in the brain, with abnormal buildup of the same protein (alpha-synuclein) in brain cells. Depending on where in the brain the buildup starts, people will exhibit one MSA subtype or the other. MSA is not considered an inherited disease, as there have been only a very small number of cases of more than one family member being affected. A variant in a gene called GBA, which encodes the enzyme glucocerebrosidase, has been found to be a little more common in people with MSA than in the rest of the population. The same finding is present in Parkinson’s disease. However, this cannot be used as a diagnostic test. A variant in a gene called alpha-synuclein (SNCA) occurs more often in people with MSA than in the rest of the population, but this accounts for only a small fraction of the overall cause of the disease and has not been confirmed in further studies. Variants in the gene encoding COQ2, an enzyme that helps in the production of coenzyme Q10, which is important to the production of energy by brain cells, were found in family members with MSA in two Japanese families where multiple members had MSA. When testing this finding among large groups of people with MSA, these COQ2 genetic variants were slightly more common among people with MSA compared to those without MSA, though this was only true in studies done in East Asian populations. Still, the vast majority of MSA is not known to have a genetic cause. Additionally, there have not been confirmed clusters of MSA related to occupation, industry, diet, ethnicity, or geography. However, one study done in North America found that occupational exposure to organic solvents, plastic monomers, metals, and pesticides was slightly higher in people with MSA. Ultimately, it is not yet known why people develop MSA. For someone who is personally impacted by MSA, we recognize that this can be extremely frustrating and confusing. Researchers and doctors are working hard to understand MSA and other neurodegenerative diagnoses, and we hope this will lead to more answers and treatment options soon. In 2020 alone, almost 500 research papers on MSA were published in scientific journals. As scientists understand more about the various neurodegenerative disorders such as Alzheimer’s disease, Parkinson’s disease, progressive supranuclear palsy, Lou Gehrig’s disease, and MSA, many commonalities among them are being revealed. There is hope that as researchers find prevention or ways of halting the progression of any of these diseases, the discovery could apply to MSA as well. Some drug companies looking for a way to slow or halt the progression of Parkinson’s disease are testing their treatments in MSA first, or simultaneously, in relation to the accumulation of the abnormally folded protein, alpha-synuclein. This has brought a wealth of new treatment trials in MSA. There is also research being done to better understand and manage the low blood pressure challenges associated with MSA. Many people with MSA find that participation in research is a meaningful way to help doctors and scientists understand, diagnose, and treat MSA. Participants in clinical trials may not only benefit from a new treatment that is not generally available; in addition, they often receive detailed care and attention that is not part of the routine, even at excellent medical centers. Equally important research is being done to look for genetic and environmental contributors to the cause of MSA, as well as research on tests that can lead to more accurate diagnosis and improved care of MSA. In the United States, clinical trials are listed on a website maintained by the National Institutes of Health, www.clinicaltrials.gov. You simply enter “multiple system atrophy” into the search box. You can also visit www.curepsp.org for a list of active and pending treatment trials in MSA. Additionally, you can ask your neurologist if they are offering or are aware of studies in MSA. Donating your brain to science can be a powerful contribution to the understanding of MSA and other neurodegenerative conditions. Each donated brain is also evaluated by a trained neuropathologist to confirm that the diagnosis of MSA was correct. Setting up brain donation needs to occur early, ideally months or even years prior to someone passing away. Visit www.psp.org/ineedsupport/ braindonation to learn about CurePSP’s brain donation program. The direct cause of MSA is not fully understood. However, we do know that it has to do with the clumps of alpha-synuclein protein. Alpha-synuclein is a protein that is normally produced in the brain. In MSA, the alpha-synuclein seems to become abnormally folded, which causes it to stick together, and become stuck inside the cell. The areas of the brain that have cells with alpha-synuclein inside of them exhibit impaired neuron function and neuronal death. One theory of the cause of MSA is that the clumps of misfolded alpha-synuclein are toxic to the brain. There is evidence of higher levels of inflammation in the brains of people with MSA, though it remains unclear whether this is a cause of the disease or a side effect of the disease process. There are also theories related to how MSA spreads through the brain. These include the idea that the diseased cells in the brain have a faulty mechanism for getting rid of waste materials, leading to cell deterioration as well as buildup of waste products such as alpha- synuclein, or that the abnormally folded alpha-synuclein protein itself “infects” other cells. The same protein, alpha-synuclein, also accumulates in the brain cells in Parkinson’s disease, but in a different pattern. In Parkinson’s disease, the accumulation of this protein is in the neurons, which are electrically active cells, primarily in the part of the brain that produces the chemical dopamine, which helps to control movement and coordination. In MSA, the alpha- synuclein accumulation and cell loss appear to mainly impact the glial cells, which are the electrically inactive supporting cells of the brain, in addition to the neurons. It is unknown why the alpha-synuclein accumulates differently in these two conditions.
CurePSP offers a variety of resources to patients and their families, other caregivers, physicians, and allied health professionals. If you do not find the information you need here, please call our office at 347-294-2873 or e-mail info@curepsp.org, and we will help you.
CurePSP encourages and organizes activities that foster face-to-face communication, exchange of ideas and information, and interaction for comfort and mutual benefit to group members. The groups are for caregivers, carepartners, family members, friends, and people with PSP, CBD, MSA, or a related disease.
Donations to the Brain Bank can make a significant impact in research. CurePSP supports the brain bank located at the Mayo Clinic in Jacksonville, FL. Brains donated there are stored and used only for research in PSP by legitimate researchers who request it. Donating to a brain bank does not interfere with funeral arrangements. Expenses for brain removal will occur, which may be reimbursed in part by CurePSP. The family will receive, at no charge, a full diagnostic autopsy report from the Mayo Clinic pathologist, Dennis W. Dickson, MD, who is one of the world’s foremost authorities on PSP and related disorders. Further information is available from CurePSP or by calling the Brain Bank directly at 904-953-2439. There are several other brain banks throughout the country, generally located at major university hospitals.
A key part of CurePSP’s mission of care, consciousness, and cure is to provide all relevant, up-to-date information on prime of life brain diseases. These resources are for patients, families, and friends seeking to educate themselves, and others, about these diseases – the causes, symptoms, trajectory, treatments, and management. This information is sourced from credible peer-reviewed scientific sources only, and is updated as breakthroughs in our understanding of these diseases occur.
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