Treatment of Multiple System Atrophy with Parkinsonism: Bradykinesia with Resting Tremor or Rigidity (MSA-P)

This protocol targets the parkinsonian type of multiple system atrophy (MSA-P), where the primary motor presentation is parkinsonism — bradykinesia accompanied by resting tremor, rigidity, or both, with or without postural instability.

Parkinsonism is the defining motor constellation of MSA-P. Bradykinesia is the core feature, combined with either a resting tremor or rigidity (or both); postural instability may also be present. Recognition of this specific motor pattern within the MSA-P subtype is essential for selecting the appropriate management strategy.

First-line management is built around a specific dopaminergic agent, administered with careful attention to autonomic tolerability — particularly orthostatic effects. An alternative dopaminergic class may also be considered, though it generally carries a less favourable efficacy and side-effect profile compared to the first-line option.

The complete first-line regimen, titration approach, monitoring parameters, and decision pathway are available in the full protocol below.