Recognizing the Signs: Motor and Autonomic Symptoms of MSA-P

While Multiple System Atrophy - Parkinsonian type (MSA-P) shares a name and several symptoms with Parkinson’s disease, it is a distinct condition with its own set of “warning signs.” Understanding these symptoms can help you and your care team manage them more effectively and differentiate MSA-P from other movement disorders ^[1].

The Two Pillars: Motor and Autonomic Symptoms

MSA-P is characterized by a “dual-system” failure involving both movement and the body’s automatic control centers ^[2].

• Motor Symptoms: These affect your ability to move and feel similar to Parkinson’s. They include bradykinesia (extreme slowness of movement), muscle rigidity (stiffness), and tremors ^[3]. In MSA-P, these symptoms typically affect both sides of the body early on, whereas Parkinson’s often starts on just one side ^[4].
• Autonomic Symptoms: These involve the autonomic nervous system, which controls involuntary tasks. The most common is neurogenic orthostatic hypotension (nOH)—a sharp drop in blood pressure when standing up that causes dizziness or fainting ^[5]. Severe bladder issues, such as urgency, frequency, or the inability to empty the bladder, also occur early in the disease ^[6].

The ‘Red Flag’ Symptoms

Neurologists look for specific “red flags” that point toward MSA-P rather than typical Parkinson’s disease. According to the 2022 Movement Disorder Society (MDS) criteria, these include:

• Early Falls: Falling within the first 3 years of noticing movement symptoms is a major indicator of MSA-P ^[7].
• Inspiratory Stridor: This is a high-pitched, strained whistling sound when breathing in, most common during sleep ^[7]. It is a critical sign that requires medical attention ^[8].
• Cold Hands and Feet: Also called the “cold hands sign,” the extremities may feel cold to the touch and appear a dusky, purplish color due to poor circulation control ^[7].
• Disproportionate Antecollis: A severe forward tilting of the neck that is out of proportion to the rest of the body’s posture ^[7].
• Rapid Progression: Symptoms that worsen quickly and do not respond well to standard Parkinson’s medications like levodopa ^[4][7].

Sleep and Swallowing Challenges

MSA-P often affects how you breathe and eat. Dysphagia (difficulty swallowing) can develop early, increasing the risk of choking or food entering the lungs ^[9].

Sleep disturbances are also common. Many patients experience REM Sleep Behavior Disorder (RBD), where they physically act out vivid or violent dreams ^[7]. While RBD is common in Parkinson’s as well, the combination of RBD with early autonomic failure or stridor is a strong indicator of MSA ^[8][7].

Why Early Symptoms Are Confusing

In the early stages, MSA-P is frequently confused with Parkinson’s disease, Progressive Supranuclear Palsy (PSP), or Pure Autonomic Failure ^[1][10]. This is because the “signature” symptoms of MSA-P, like the cold hands sign or severe stridor, may not appear all at once. Monitoring these signs over time is the most effective way for your specialist to confirm the diagnosis ^[7].