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Table 2 Red flags for MSA, reproduced with the courtesy of Wiley and Sons [85]

From: An update on the cerebellar subtype of multiple system atrophy

Red flag

Definition

Early instability with recurrent falls

within 3 years of disease onset

Rapid progression

“wheelchair sign”: dependent < 10 years from disease onset

Orofacial dystonia

based on clinical judgment

Camptocormia

prolonged episodes of forward trunk flexion

Pisa syndrome

prolonged episodes of lateral trunk flexion

Disproportionate antecollis

severe neck flexion, minor flexion elsewhere

Contractures of hands or feet

excluding Dupuytren’s or contracture due to other known cause

Jerky tremor

irregular postural or action tremor of the hands and/or fingers with definite myoclonus

Diurnal inspiratory stridor

based on clinical judgment

Nocturnal inspiratory stridor

based on clinical judgment

Inspiratory sighs

involuntary deep inspiratory sighs/gasps

Severe dysphonia

based on clinical judgment

Severe dysarthria

based on clinical judgment

Severe dysphagia

based on clinical judgment

REM sleep behavior disorder

intermittent loss of muscle atonia and appearance of elaborate motor activity (striking out with arms in sleep often with talking/shouting) associated with dream mentation

Sleep apnoea

prolonged arrests of breathing

Excessive snoring

increase from premorbid level, or newly arising

Cold hands/feet

new development of coldness and color change – purple/blue – of extremities, with blanching on pressure and poor circulatory return

Raynaud’s phenomenon

new emergence of painful “white fingers”

Emotional incontinence – crying

Inappropriate crying without sadness

Emotional incontinence – laughing

Inappropriate laughing without mirth

Past history of documented hypertension

based on clinical judgment