What Are the Best Physical Therapy Exercises for MSA?

Physical therapy is an essential part of managing balance and walking difficulties associated with Multiple System Atrophy (MSA). While medications can help with some symptoms, physical therapy provides vital non-pharmacological support to improve your gait (how you walk), maintain your independence for as long as possible, and reduce your risk of falls ^[1][2]. Because MSA involves both movement difficulties and autonomic nervous system issues—such as blood pressure dropping when you stand (orthostatic hypotension)—your physical therapy program must be carefully tailored by a specialist, ideally a neurological physical therapist, to keep you safe during exercise ^[1][3].

Core Focus Areas for MSA Physical Therapy

Managing your motor symptoms requires a multidisciplinary approach ^[1][4]. While physical therapy focuses on your walking and lower body, an occupational therapist can assist with upper body function and daily living activities ^[1][5]. Preliminary evidence shows that targeted physical therapy is safe and can improve how you walk ^[2].

Gait Training and Balance

Because MSA can cause stiffness, slowness, and coordination problems, physical therapists often focus on gait training—exercises designed to improve your walking pattern and efficiency.

• Core stability: Strengthening the muscles of your abdomen and back helps provide a stable foundation, which is necessary for maintaining your balance and coordinating your limb movements ^[1][4].
• Balance exercises: Your therapist will teach you exercises that challenge your balance in a controlled environment, helping your brain and body communicate better to keep you upright ^[1][4].

Fall Prevention Strategies

Falling is a significant risk in MSA, often due to a combination of balance problems, coordination deficits, and sudden blood pressure changes ^[1][6]. Your physical therapist can help you by:

• Teaching you how to turn and change directions safely without losing your balance ^[1].
• Assessing your need for assistive devices. If a wheeled walker (rollator) is needed, they may recommend one with resistance brakes, as standard walkers can sometimes roll too quickly and increase fall risk if you lean forward ^[1][6].
• Instructing you on how to get up safely from a chair or bed to minimize dizziness ^[1].

Exercising with Orthostatic Hypotension

Orthostatic hypotension is a rapid drop in blood pressure when you sit up or stand, causing dizziness, lightheadedness, or even fainting (syncope) ^[7][3]. It is a defining feature of MSA and a major contributor to falls ^[6][8]. To exercise safely, your routine must be adapted:

• Seated or Supine Exercises: To minimize blood pressure drops, many exercises should be performed while seated or lying down (supine) ^[1][3]. For example, a therapist might recommend seated leg extensions or seated marches, allowing you to build strength without fighting gravity’s effect on your blood pressure ^[1][3].
• Aquatic Therapy (Water Exercise): Exercising in a pool is often highly recommended. The water provides buoyancy, which supports your body and reduces the fear of falling, while the water pressure gently helps keep blood from pooling in your legs, supporting better blood pressure control ^[1][9].
• Slow Transitions and Ankle Pumps: Avoid rapid changes in posture. When moving from lying to sitting, or sitting to standing, do so very slowly ^[7][10]. A common strategy is to sit on the edge of the bed for a few minutes and perform “ankle pumps” (moving your feet up and down) to help push blood back up toward your heart before you stand ^[3][10].
• Supportive Gear: Wearing compression garments (like abdominal binders or compression stockings) during exercise is a standard recommendation to improve your exercise tolerance and cardiovascular stability ^[1][3]. Staying well-hydrated is also crucial ^[1].

Managing Fatigue and When to Stop Exercising

MSA patients often experience severe fatigue. Learning to pace yourself and not over-exert during physical therapy is crucial, as pushing too hard can worsen your symptoms ^[1][4].

Your safety is the highest priority. You should modify or stop your therapy session if you experience “red flag” symptoms such as:

• Severe dizziness, lightheadedness, or feeling like you might faint ^[11][3].
• “Coat-hanger” pain (a specific type of neck and shoulder ache that signals low blood pressure) ^[3][12].
• Respiratory distress or shortness of breath ^[11][12].

Always work with a physical therapist who understands movement disorders and autonomic nervous system dysfunction, so they can monitor you and adjust your program as your needs change ^[1][5].