Multiple System Atrophy - A brief guide:

Multiple System Atrophy (MSA) is a progressive neurological disorder that affects adult men and women. MSA is caused by degeneration of nerve cells in specific areas of the brain. This cell degeneration causes problems with movement, balance and automatic functions of the body such as bladder control.

How common is MSA?

Until recently MSA was thought to be a very rare disorder. As we learn more about the condition, it becomes easier to recognise and diagnose. Recent research suggests that MSA affects 5 people per 100,000 in the UK. This means that there may be up to several thousand people with MSA at any time in the UK.

Who has MSA?

MSA usually starts between the ages of 50-60 years, although it can affect people younger and older than this. MSA does not appear to be hereditary and is not infectious or contagious. It is a sporadic disorder that occurs at random.

What does MSA mean?

The term Multiple System Atrophy was first used in 1969, although it has been called many things including; olivopontocerebellar atrophy, striatonagral degeneration, Parkinson's plus and Shy-Drager Syndrome. The confusion caused by this variety of names led to an international consensus by medical experts in 1996 to use the term Multiple System Atrophy (MSA).

Broken down MSA stands for:
Multiple - many
System - brain structures that control different functions
Atrophy - cell shrinkage or damage

This means that cells are damaged in different areas of the brain that control different body functions. The three areas affected are the basal ganglia, cerebellum and brain stem. These areas are responsible for movement, balance and automatic body functions like bladder control.

How are the nerve cells in the brain damaged in MSA?

Nerve cells in the affected areas of the brain shrink (atrophy). This can sometimes be seen on MRI scans. When brain tissue is examined under a microscope, structures called glial inclusion bodies can be seen; they contain a protein called alpha-synuclein. It is the presence of these inclusion bodies in the movement, balance and automatic control centres of the brain that confirms a diagnosis of MSA.

Why do nerve cells become damaged?

It is still unclear as to exactly why the cells become damaged in MSA. MSA is not contagious. It does not appear to be inherited, although there may be a predisposition within the genetic make-up of an individual for cells to become damaged. What triggers the damage process to begin is unknown. This is a focus of ongoing research.

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What are the first signs of MSA?

For men, the first sign is often erectile dysfunction (unable to achieve or sustain an erection). Both men and women often have early bladder problems: urgency, frequency, incomplete bladder emptying or an inability to pass urine (retention). These problems may sometimes be incorrectly attributed to the ageing process or to prostrate disease in men.

Other early problems can be feeling stiff and slow and finding movement difficult, feeling dizzy when standing up, fainting, difficulty turning in bed, and changes in writing. Some people become clumsy or unsteady when walking.

However these early symptoms could also be due to a range of other diseases which need to be excluded before a diagnosis of MSA can be made.

What happens next?

MSA is a progressive disease - this means that your symptoms will change over a period of time and you will need more help to care for yourself. The speed of these changes is difficult to predict as people with MSA experience the disease differently. Some people feel they cope better when they know what lies ahead. You can discuss the future with your specialist or the Sarah Matheson Trust (SMT) nurses.

What else happens in MSA?

There are three groups of symptoms. They are sometimes called

• parkinsonism (slow, stiff movement),
• cerebellar (co-ordinating movement and balance)
• autonomic (automatic body functions)

Parkinsonism

• feeling slow and stiff when moving
• difficulty turning in bed
• difficulty in starting to move
• writing becoming small and spidery

Cerebellar

• feeling clumsy, dropping things
• finding it difficult to fasten buttons
• feeling unsteady in crowds
• unable to balance without support
• difficulty writing
• slurred speech

Autonomic

• bladder problems
• difficulty with erections
• feeling dizzy or fainting (blood pressure problems)
• pain around neck and shoulders
• constipation
• cold hands and feet
• inability to sweat

Other problems

• weakness in arms and legs
• heightened emotional response, laughing or crying
• restless sleep
• nightmares
• noisy breathing during the day, snoring at night
• unintentional sighing
• swallowing problems, difficulty chewing, choking episodes
• weak, quiet voice

Having a diagnosis of MSA does not mean you will experience all of these symptoms.

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What is the treatment for MSA?

Treatment for MSA involves a combination of medication, specialised equipment and the use of therapists to manage individual symptoms. Your treatment will usually be managed by a neurologist or physician who has specialised in movement disorders or autonomic disorders. The complex nature of MSA means that the best treatment is gained from a multidisciplinary team approach. A multidisciplinary team is a group of health and social care professionals.

Some members of the multidisciplinary team may not previously have treated anyone with Multiple System Atrophy. Don't be discouraged by this. The Sarah Matheson Trust can provide them with information and advice. All they need is to be enthusiastic about your care.

Any of these members of a multidisciplinary team may be involved in your care:




What medication can I take?

Medication regimes will vary depending on your symptoms. Your specialist will prescribe the best combination to meet your needs. Here are some of the medications commonly used in MSA.

Movement problems - drugs to help stiffness and slowness are the same drugs used in Parkinson's disease (PD). They are not as effective in MSA and can make blood pressure problems worse. It may take time to find what suits you best.

• L-Dopa (Madopar or Sinemet)
• Amantadine (Symmetrel)

Blood pressure problems - drugs to control the fall in blood pressure can be effective in reducing dizziness, fainting and falls. These drugs may cause high blood pressure when lying down. It is advisable to raise the head of your bed and have regular blood pressure checks.

• Fludrocortisone (Florinef) - A steroid, taken in very small doses; may cause ankle swelling.
• Ephedrine - Works quickly to raise the blood pressure, usually taken three times a day.
• Midodrine (Gutron) - Works quickly to raise the blood pressure (within 30-60 minutes), usually taken three times a day. Only prescribed by specialists.

Bladder problems - drugs can reduce urgency and frequency problems

• Oxybutinin (Ditropan) - improves bladder control
• DDAVP (Desmopressin) - used to reduce the production of urine overnight

Antibiotics - should be prescribed at the first signs of infection. Any infection in someone with MSA can worsen symptoms like postural hypotension dramatically.

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What about complementary medicine?

There is no evidence to recommend a specific therapy in MSA but some people find complementary medicine useful. Discuss with your specialist or GP before trying any of these. Bear in mind that very few of these therapies are funded on the NHS. Use a therapist who is a member of the appropriate governing body e.g. The British Homeopathic Association. For further advice contact the Institue of Complementary Medicine.

What about the future?

Many of the ideas and plans you had for your future will change once you have MSA. People adjust to this change in different ways. There is no simple recipe to help you cope but there are lots of people out there who can help you, and not least of these is the Sarah Matheson Trust.

Thinking ahead and talking things through with your family can help ease the path in front of you.

Progress in treating MSA is steady and hopeful as increased awareness and understanding of this unique disorder gains momentum.

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