Table 6

General approach to managing motor symptoms in MSA

SymptomTreatment approach
  • Early referral to physiotherapy and occupational therapy to help maintain independence for as long as possible.

  • All parkinsonian patients should have a slow uptitration L-dopa trial to at least 1 g a day for 3 months.

  • Down-titrate L-dopa medication when/if it is no longer perceived to be effective, but reinstate the last dose if there is a deterioration.

  • In patients with orthostatic hypotension, consider simultaneous midodrine if there are at least 4 hourly intervals between L-dopa doses.

  • Modified release L-dopa can help nocturnal symptoms but be cautious about nocturnal hypotension, in particular in those with nocturia and mobility issues.

Ataxia and vertigo
  • There is no proven effective pharmacotherapy for this.

  • Early referrals to physiotherapy and occupational therapy.

  • Review medications and stop unnecessary muscle relaxants or daytime sedatives, to help balance.

  • Look for and treat concomitant reversible causes of vertigo.

  • Early referrals to physiotherapy and occupational therapy .

  • Consider DEXA scanning and FRAX score calculation and manage for osteoporosis

  • Determine whether dystonia is secondary to levodopa-induced dyskinesia (ie, increases at peak dose); if so adjust medication accordingly

  • Treatment naïve/wearing off dystonia may respond to levodopa.

  • Focal dystonia can respond to botulinum toxin injections, while generalised dystonia may respond to clonazepam 0.5–1 mg or baclofen 5 mg three times a day. This should be done in conjunction with physiotherapy for splinting

  • Anticholinergics can be tried, but autonomic adverse effects may limit their use.

  • Physiotherapy referral for stretching and splinting alongside botulinum toxin can help.

  • DEXA scan, dual-energy X-ray absorptiometry scan; FRAX, Fracture Risk Assessment Tool; MSA, multiple system atrophy.