Wijdicks, Eelco F. M. MD
Parkinson's disease (PD) has rarely been portrayed in contemporary cinema, but when it has, most often the films portray the disease in its late disabling stage. The 1990 film, “Awakenings” — starring Robert De Niro — focused on post-encephalitic parkinsonism. More recently, the 2010 film, “Love and Other Drugs” depicted a patient with early Parkinson's disease, played by Anne Hathaway, but the accuracy of that portrayal was subject to some debate, and the portrait of PD was overshadowed by a nonsensical plot.
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A far more restrained film, “A Late Quartet” — with strong acting by Philip Seymour Hoffman, Mark Ivanir, Catherine Keener, and Christopher Walken, and wonderful direction by Yaron Zilberman — does a much better job of portraying how the disease can affect an individual over time. Released in 2012, it focuses on the consequences of an early diagnosis of Parkinson's disease on a musician in a closely-knit string quartet, celebrating its 25th anniversary.
When professional musicians develop Parkinson's disease, it often ends their careers, and sadly, early on in the process. The inability to quickly switch finger positions can result in the loss of tempo, and playing long stretches of music that requires close harmonization with other musicians can be quite difficult. Playing complex musical parts not only becomes physically demanding, but memorizing transitions and the need for sustained attention becomes challenging when cognition becomes impaired in later stages.
“A Late Quartet” presents a very accurate representation of that process — and its attendant struggles for a musician. Christopher Walken plays Peter, the cellist and founder of this quartet, who discovers during a practice session that he cannot move his left hand and fingers well enough to produce a colorful vibrato (oddly enough primarily a hand shaking oscillating movement). The neurologist, played by an award-winning Indian actress Madhur Jaffrey, is compassionate. She instructs Peter to make rapid hand opening and closing movements, to stand up and to walk a few steps and turn around. He shows left-sided hypokinesis with no arm swing, gait and balance instability.
The meeting with the neurologist is notable in particular because Peter is surprised that it is a clinical assessment and not a laboratory test with a positive or negative result. When he questions whether she can really make the diagnosis without tests, she answers: “I am afraid I can.” Peter's response (“wow”) accurately reflects the common surprise that patients express when they are so quickly and confidently diagnosed with a neurologic illness.
The consequences of the diagnosis are substantial and Peter knows that his replacement should be found despite being treated with medication. “I may be able to play one season, but then it will be over,” he tells his fellow quartet members. He explains that it will be a struggle to adjust to one another being out of tune. For all of them it is clear that their season's musical centerpiece — Beethoven's late string quartet Opus 131 in C-minor with its 40 minutes of uninterrupted playing — requires perfect motor movements. A hurdle that even their most practiced of cellists cannot overcome.
After this announcement everything falls apart and, although it has a mundane plot, the remainder of the film remains well worth watching. Christopher Walken may be the most ideal actor to play the part; his depiction of hypokinesis and lack of mimicry is pitch-perfect. (Playing a subdued and monotonous character is one of Walken's trademarks.) As befits a serious film, it also shows a Parkinson's rehabilitation group — the Brooklyn Parkinson's group known for dance therapy — where it is emphasized that “in Parkinson's disease everything gets small…everything contracts and closes in” and the goal is to “push those boundaries out.”
After treatment with levodopa, Peter has a brief visual hallucination where he sees his late wife (a mezzo-soprano) singing. There is also an episode where he contemplates suicide — all familiar issues in the long-term management of Parkinson's disease.
One day, suddenly and much to his surprise, he discovers during a teaching class that he is able to play very well (“the medication is working”) and he rallies his quarter members to practice again. In the time he has been away, however, many things have changed; he discovers that the supposedly coherent and civilized quartet has fallen apart due to marital problems and flings left and right. The quartet explodes during a practice session in a cathartic (and comical) scene. Nevertheless, the quartet reconvenes and the new season starts. Peter knows that he cannot play the Presto 5th movement of Beethoven's late quartet and he suddenly stops during the first performance. After a moving speech, he introduces a replacement cellist.
The film shows the enormous impact a tiny change in motor function can bring about — common knowledge for all neurologists first diagnosing a neurodegenerative disease. During this farewell speech Peter explains that he cannot keep up and he cannot play the piece in one uninterrupted session (attacca): “It is Beethoven's fault,” he says. Neurologists and, in particular, neurologists who are also musicians should be enamored by this statement. It is an outstanding film.
Dr. Wijdicks is professor of neurology at Mayo Clinic in Rochester, MN.