Perspective

Frida Kahlo:
Frida Kahlo:
Portrait PortraitPain
of Chronic of Chronic Pain
Carol A. Courtney, Michael A. O’Hearn, Carla C. Franck
C.A. Courtney, PT, PhD, ATC, C.A. Court
Department of Physical Therapy,
­ The Mexican artist Frida Kahlo (1907–1954) is one of the most celebrated artists of the 20th Departmen
­University of Illinois at Chicago, 1919 W
century. Although famous for her colorful self-portraits and associations with celebrities Diego University
Taylor St, 4th Floor, Chicago, IL 60612 1919 W Ta
Rivera and Leon Trotsky, less known is the fact that she had lifelong chronic pain. Frida Kahlo
(USA). Address all correspondence to cago, IL 60

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Dr Courtney at: cacourt@uic.edu.
developed poliomyelitis at age 6 years, was in a horrific trolley car accident in her teens, and correspond
would eventually endure numerous failed spinal surgeries and, ultimately, limb amputation. at: cacourt@
M.A. O’Hearn, PT, MHS, Department of She endured several physical, emotional, and psychological traumas in her lifetime, yet through
Physical Therapy, University of Illinois at her art, she was able to transcend a life of pain and disability. Of her work, her self-portraits M.A. O’Hea
Chicago, and Department of Physical
are conspicuous in their capacity to convey her life experience, much of which was imbued ment of Ph
Therapy, Lakeland HealthCare, Saint sity of Illin
with chronic pain. Signs and symptoms of chronic neuropathic pain and central sensitization
Joseph, Michigan. Departmen
of nociceptive pathways are evident when analyzing her paintings and medical history. This Lakeland
C.C. Franck, PT, DPT, Department of article uses a narrative approach to describe how events in the life of this artist contributed to Joseph, Mic
Physical Therapy, University of Illinois her chronic pain. The purpose of this article is to discuss Frida Kahlo’s medical history and her
at Chicago. art from a modern pain sciences perspective, and perhaps to increase our understanding of the C.C. Franck
pain experience from the patient’s perspective. of Physical
[Courtney CA, O’Hearn MA, Franck CC.
Illinois at C
Frida Kahlo: portrait of chronic pain.
Phys Ther. 2017; 97:90–96.] [Courtney
Franck CC.
© 2017 American Physical Therapy
chronic pa
Association
97:xxx–xxx
Published Ahead of Print:
August 25, 2016 © 2017 Am
Accepted: July 7, 2016 Association
Submitted: January 27, 2016
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August 25
Accepted: Ju
Submitted:

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90    Physical Therapy  Volume 97  Number 1 January 2017

Frida Kahlo
L ike many debilitating diseases, the
impact of chronic pain is poorly
understood in society, even among
health care providers who may lack an
appreciation of the underlying mecha-
nisms and wide-ranging consequences of
this progressive condition. In recent
years, chronic pain has been classified as
a disease process due to its progressive
and debilitating nature.1,2 Although
researchers have made great strides in
understanding pain science, clinical
knowledge and expert management of
this disease remains inadequate in the
medical community.3 The backbone of
clinical expertise is advanced clinical rea-
soning, which has been described as the
thinking and decision-making processes
used in clinical practice.4 One such
example of this is narrative reasoning.5
Narrative reasoning seeks to understand
the unique experiences of patients
through storytelling. In the context of
clinical practice, narrative reasoning is
defined as the appreciation of patients’
stories in order to gain insight into their
experiences of disability or pain.4 The
life and art of the Mexican painter Frida
Kahlo provides just such a narrative. By
exploring her history, the underlying
neurophysiological mechanisms and
clinical presentation of chronic pain may
be further appreciated. The primary pur-
pose of this article is to enhance under-
standing of the experience and underly-
ing science of chronic pain through the
narrative of Frida Kahlo.
The artist Magdalena Carmen Frieda
Kahlo y Calderón was born in a suburb of
Mexico City on July 6, 1907.6 As a femi-
nist, political activist, and painter, Frida
Kahlo was truly a revolutionary born dur-
ing a revolutionary period of Mexican
history. Although Mexico’s artistic focus
was often directed toward European his-
tory and culture at the turn of century,
the 1910 Mexican Revolution produced
a significant transformation in Mexican
self-identity.6 Escape from European tra-
ditions allowed Mexico to reinvent itself
and to rewrite its history, where a new
understanding of Mexican culture was
developing. Intelligent and naturally gre-
garious, it is likely that Frida Kahlo
thrived in this environment of radical
nationalism, where creativity and origi-
nal thinking were encouraged. Frida
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January 2017 Therapy Volume 97 Number 1
Kahlo is arguably one of the most influ-
ential artists of the 20th century, and her
work has continued to gain prominence
worldwide. Central to her life story and
development as an artist were a series of
life events that left her in chronic pain
(Fig. 1). Even though numerous art his-
torians and biographers have detailed
these life events and analyzed her work,
less is understood about the neurophys-
iological basis of her condition.
The science underlying chronic pain has
developed rapidly over the past 50 years,
fueled by the increased prevalence of the
condition to near-epidemic proportions.
It is now estimated that almost 30% of US
adults have chronic pain.7 The discovery
that pain processing is mutable triggered
a major shift in pain science. Previously,
the scientific community believed that
pain behaved in a stimulus/response
manner (ie, a stimulus was applied, and
pain was elicited). Likewise, when the
stimulus was removed, pain ceased.
However, research during the 1980s
revealed that neural pathways carrying
the pain message can “learn.”8 Just as a
student might memorize multiplication
tables by repetition, neurons carrying
the pain signal can become more effi-
cient at delivering their message. Even-
tually, as this “lesson” continues, the
pain may be experienced even without a
stimulus. Thus, the individual with
chronic pain may experience severe
spontaneous pain, and patients, family
members, and health care providers are
often perplexed in their attempts to alle-
viate the suffering. In recent years, sci-
ence has made great strides in under-
standing not only the pathophysiology of
chronic pain but also the various factors
that may contribute to aberrant pain pro-
cessing. Thus, when knowledgeable on
the topic, researchers and practitioners
alike are beginning to more readily iden-
tify features of the disease process. This
altered mind-set toward the patient with
chronic pain may signal a shift in medical
and physical therapy treatment of this
patient population.9,10 Individuals with
chronic pain may demonstrate multiple
areas of pain, heightened intensity of
symptoms, spread of symptoms, and
seemingly unrelated sensory and neuro-
vascular phenomena.11 How these signs
and symptoms are interpreted is critical
Volume 97  Number 1  Physical Therapy  91
Frida Kahlo
for appropriate rehabilitative decision
making.
The art of Frida Kahlo tells an intimate
story, one so original and so unique that
it has inspired people from around the
world. Chronic pain, like many chronic
diseases, can lead to suffering and social
isolation. Perhaps the broad appeal of
Frida’s work relates to her ability to pull
back the curtain and expose this margin-
alizing experience. By understanding the
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underlying science, it is possible to gain
a small window into the life experience
of this extraordinary artist. A secondary
purpose of this article is to relate events
in the life of Frida Kahlo and her available
medical data to the current medical sci-
ence of chronic pain.
A Childhood of Trauma
Frida Contracts Poliomyelitis
At age 6 years, Frida contracted poliomy-
elitis, which is more commonly known
as polio. Polio is a crippling and poten-
tially deadly infectious disease caused by
the poliovirus. Her contraction of the
disease coincided with the first large out-
break in the United States in 1916, with
more than 27,000 cases and more than
6,000 deaths.12 Frida remembered expe-
riencing at the time “a terrible pain in her
right leg.”6 Her convalescence was
lengthy, requiring her to spend 9 months
in bed.13 She was left with characteristic
sequelae of the disease: muscle atrophy
and weakness. In addition, Frida’s medi-
cal records indicate that her limb failed
to develop compared with her unaf-
fected limb.14 This leg-length discrep-
ancy would have caused an imbalance in
pelvic alignment during stance, resulting
in a functional scoliosis or curvature of
her spine.15
Although estimates vary, a large majority
of individuals with polio will eventually
develop post-polio syndrome.16,17 Post-
polio syndrome has a latency of approx-
imately 15 or more years,16 which sug-
gests that Frida could have experienced
it in her 20s or beyond. Chronic pain and
fatigue are the most prevalent symptoms
in this condition.17 Pain is not only com-
mon in people with post-polio syn-
drome, but often is rated as moderate to
severe and frequently occurs in many
locations around the body.18 Using the
January 2017
Frida Kahlo
Figure 1.
Frida Kahlo’s journey into chronic pain.
Nottingham Health Profile questionnaire,
individuals with post-polio syndrome
were found to have higher levels of dis-
tress in the dimensions of energy, phys-
ical mobility, pain, sleep, and emotional
reactions than a group without post-
polio syndrome.19 A number of chronic
pain syndromes share these same signs
and symptoms. Proposed theories on the
underlying pathogenesis of this syn-
drome are variable and include: (1)
degeneration of the enlarged motor units
that develop after acute poliomyelitis,
(2) a chronic persistent poliovirus infec-
tion, or perhaps (3) an immune-mediated
disorder.16 Coolness and color changes
such as cyanosis and blanching of the
affected extremity also may occur in
post-polio syndrome,20 indicative of vas-
cular insufficiency. Smith et al21 sug-
gested that these vascular changes may
relate to sympathetic intermediolateral
column damage from the acute polio-
myelitis. Regardless of the cause, it is
known that Frida ultimately experienced
vascular insufficiency, which led to sub-
sequent amputations.14 Understanding
what is now known about this disease,
many of Frida’s signs and symptoms
could easily be attributed to post-polio
syndrome.22 However, another event in
late childhood would overshadow this
part of her medical history.
Terrible Streetcar
Frida Survives a Terrible
Streetcar Accident
Accident
Despite her childhood illness, Frida grew
into a lively, intelligent young girl. She
was accepted into the Escuela Nacional
Preparatoria, the best educational institu-
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Physical Therapy  Volume 97  Number 1
tion in Mexico, where she was 1 of only
35 girls in a school of 2,000 students.6
Her plan was to study medicine. At age
17 years, while traveling home from
school, the bus on which she was riding
was hit by a streetcar. She sustained sig-
nificant trauma, including multiple frac-
tures of the clavicle, ribs, spine, elbow,
pelvis, leg, and foot. Her right foot was
crushed, and both ankles and shoulders
were dislocated. In addition, she was
pierced by an iron handrail from the
streetcar that entered her left hip and
exited through her pelvic floor.6 She was
not expected to survive. Frida developed
both peritonitis and cystitis, which, in
the era before the use of antibiotics,
were often fatal.13 Frida did survive this
accident, although a long convalescence
was required. Even though her body tis-
sues healed following the accident, it
was during this time that the slow insid-
ious onset of chronic pain would have
commenced. Over time, she developed a
number of medical conditions that likely
contributed to or facilitated her chronic
pain.
Pain: Frida’s Constant
Companion
Low Back Pain
Back pain was one of Frida’s main com-
plaints following the streetcar accident.6
In later years, while traveling with her
husband, Diego Rivera, Frida would con-
sult with Dr Leo Eloesser, a San Francisco
physician. They became lifelong friends.
Through radiographic imaging, Dr
Eloesser diagnosed a congenital scoliosis
of her lumbar spine.6 Whether this was a
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Frida Kahlo
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congenital scoliosis or functional scolio-
sis ensuing from her leg-length discrep-
ancy, the result of either could cause
concern. Although scoliosis often may
predispose an individual to back pain,
Frida’s multiple spinal fractures would
represent a trauma superimposed on a
biomechanical deficit. The result could
potentially accelerate spinal degenera-
tion and pain.15 Dr Eloesser also diag-
nosed a missing vertebra.13 This finding
may have represented a congenital
sacralization of the fifth lumbar vertebra,
which occurs in approximately 12% of
the population,23 or a consequence of
her accident or surgeries, or both. Inter-
estingly, Eloesser recommended bed
rest, a more nutritious diet, cessation of
alcohol consumption, and “therapy.”13
Most of these recommendations, with
the exception of bed rest, would still be
considered excellent advice in the mod-
ern day.
Surgical intervention may be beneficial
for some patients; however, in certain
individuals with chronic pain, surgery
may serve as a further insult to the sys-
tem, facilitating aberrant pain process-
ing. Although surgical goals (eg, stabili-
zation) may be accomplished, symptoms
may be unchanged or worsened. Failed
back surgery syndrome is a potential
consequence for patients with chronic
spine pain who are considering a surgical
solution, and the incidence of this out-
come ranges between 5% and 50%.24 The
painting Tree of Hope, Keep Firm (1946)
shows the healthy and able Frida staring
into the future as the broken Frida lies in
Number 1 Physical Therapy
January f 3
2017
Frida Kahlo
Figure 2.
The Broken Column, 1944 (oil on Masonite. Masonite Corp, Tampa, Florida), Kahlo, Frida
(1907–1954)/Museo Dolores Olmedo Patino, Mexico City, Mexico/© Leemage/Bridgeman
Images/Permission Artists Rights Society, New York, New York.
the bed facing away. In this painting,
Frida portrays the surgery as a large, jag-
ged bleeding incision. Although she bids
herself to “stay strong,” in reality, the
spinal fusion was a failure and may have
been the turning point in her decline,
leading to her death.6
In 1950, following several previous spi-
nal surgeries, a spinal fusion of 4 lumbar
vertebrae was recommended. During
this surgery, bone was harvested from
her iliac crest and inserted for the pur-
4 f Physical
January 2017 Therapy Volume 97 Number 1
Frida Kahlo
doubled in one study of postsurgical out-
comes in smokers.26
Frida’s struggle with chronic back pain
and failed surgeries is further repre-
sented in her 1944 work, The Broken
Column (Fig. 2). In this image, her spinal
column is replaced by a broken Doric
column and her trunk bound by a corset.
The uncertain bindings of the leather
corset seem to portray her view of the
precarious nature of her own back. Body
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image can be disrupted in people with
pain disorders, including low back
pain.27 The Broken Column may depict
this disruption of body image through
the image of the trunk rendered into 2
halves, held together tenuously by the
straps of the corset. Perhaps more appar-
ent, is the contrast of her broken body
and the fortitude displayed in her
countenance.
Neuropathic Pain
An important factor contributing to Fri-
da’s chronic pain was the very real pos-
sibility that she sustained nerve damage
during the streetcar accident. In her let-
ters, she intimated, “The sciatic nerve is
damaged as well as another nerve. . .to
the genitals.”28 She dealt with spine-
related leg pain for the rest of her life.13
In her painting The Broken Column
(Fig. 2), large nails pierce the skin of her
right lower extremity, representing the
chronic leg pain she experienced.13 Ana-
tomically, it is known that nerves are
composed of various types of neurons
that transmit information throughout the
nervous system. Nerve injuries trigger
molecular changes in neurons that trans-
mit pain and, following injury, may
develop abnormal sensitivity and sponta-
neous activity.29 Ultimately, the central
nervous system may become sensitized
and pain easily triggered. The potent
pose of fusing spinal segments, limiting
imagery in What the Water Gave Me
movement and diminishing pain. The
(1938) (Fig. 3) has been interpreted in
surgery was a failure, and bone infection
many ways6,30; however, these images
(ie, osteomyelitis) was induced. The
also may represent, in part, her chronic
result was a draining, infected wound.
right leg pain. In this painting, the artist’s
Gamble13 noted that it is now known
limbs are partially immersed in a bath.
that long spinal fusions are difficult to
Over her right limb is a volcano with lava
accomplish in the lumbar spine. In addi-
streaming from its cone, potentially rep-
tion, Frida was a heavy smoker, and
resenting the unpredictable burning
smoking is a known risk factor for failure
nature of her pain. Out of the volcano
of spinal surgery.25 In fact, the rate of
protrudes a modern skyscraper, having
nonunion (failure to fuse) was almost
no effect on the flow of lava, perhaps
January 2017
Volume 97  Number 1  Physical Therapy  93
Frida Kahlo Frida Kahlo

signifying the failure of modern health

care at the time to provide relief.13 Peo-
ple with neuropathic pain often com-
plain of spontaneous pain, described as
shooting and burning,31 and experi-
enced with little or no provocation. This
pain has been attributed to the aberrant
development of ectopic action potentials
in neurons responsible for transmitting
pain messages.32 The term “ectopic” in
this instance signifies not only that the
pain generator is “out of place” but also

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that the impulse may fire without stimu-
lus, thus generating spontaneous pain.

As a feature of her neuropathic pain,

Frida may have experienced allodynia,
defined as the elicitation of pain with a
non-noxious stimulus.31 Pain is typically
experienced when a stimulus reaches a
certain threshold for pain receptors to
perceive the input. Allodynia can be elic-
ited with light touch of the skin, indicat-
ing that input to non-pain receptors may
trigger the pain message. In the case of
mechanical allodynia, even the touch of
clothing may evoke severe pain. Allo-
dynia can occur with warm and cold
sensory input as well. A warm bath,
which may be relieving to some, could
be the source of burning pain in a person
with allodynia. Studies have confirmed
that neuropathic pain can become recal-
citrant and very difficult to treat,29
particularly as it is associated with hyper-
sensitivity of central pain processing.
Characteristic of centrally mediated pain
is the fact that pain intensity becomes
amplified and the distribution of pain
expands over time.11 This would mean Figure 3.
that Frida’s leg pain would have wors- What the Water Gave Me, 1938 (oil on canvas), Kahlo, Frida (1907–1954)/Christie’s Images/
ened and expanded beyond the original Photo © Christie’s Images/Bridgeman Images/Permission Artists Rights Society, New York,
distribution of pain. With the severity of New York.
her injuries, this likely occurred. It is
clear that Frida suffered tremendously
from this aspect of her condition. deformed, with a jagged unhealed as one of the sequelae of post-polio syn-
wound. In 1936, the sesamoids of her drome.20 By 1944, she was living with
A Slowly Dying Limb foot were excised and a sympathectomy unremitting pain,13 and more than one
While in San Francisco, Frida’s signs of was performed for the purpose of regain- medical expert has suggested that she
vascular insufficiency were addressed ing circulation.13 Sympathectomy is a may have transitioned to complex
medically.13 She developed a trophic surgical ablation performed by open regional pain syndrome I or II,14,35 a form
ulcer on her right foot, which would interruption of the nerves of the sympa- of severe chronic pain, typically affecting
progress in the following years, eventu- thetic chain near the spinal cord. It has one of the limbs, that occurs with or
ally resulting in excision of 5 phalanges been used medically for varying reasons, without nerve injury. In 1953, Frida
in 1934. Vascularity continued to be an both for relief of pain33 and to promote required amputation of her right lower
issue, and gaining wound closure was vasodilation.34 In Frida’s case, there may limb due to gangrene.14
difficult. In What the Water Gave Me have been neurovascular damage when
(Fig. 3), Frida portrays her right foot as her right foot was crushed. Alternatively,
vascular compromise has been identified

January
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Physical Therapy  Volume 97  Number 1 Volume 97 Number 1 Physical Therapy
January f 5
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Frida Kahlo
Psychological/Emotional Pain
Considering the numerous physical and
emotional traumas in her life, it is per-
haps not surprising that she struggled
with mental illness. Frida was a charis-
matic and vibrant personality6; however,
some sources have described her as a
woman with emotional instability and
low-grade depression.6,36 During certain
stages of her life, she was plagued by
major depressive episodes and suicidal
thoughts. Her chronic pain, multiple mis-
carriages, and the recurrent infidelities of
her husband, Diego Rivera, would serve
as triggers for these psychological disrup-
tions. Heightened emotional or psycho-
logical stress may contribute to the
chronic pain experience.37 It is likely
that Frida had mixed feelings about hav-
ing a child. She had voiced concern
about the passing of genetic traits for
epilepsy (which her father had) and her
own ability to deliver a child considering
the previous trauma to her pelvis, and
she expressed anxiety about how a child
would affect her relationship with
Diego.6 Prior to one of her miscarriages,
which was the basis of her painting,
Henry Ford Hospital (1932), she had
already had one abortion. It was during
this pregnancy, while in Detroit, that her
physician gave her a dose of castor oil
and quinine for the purpose of inducing
an abortion at 8 weeks.6 Both castor oil
and quinine have the effect of stimulat-
ing uterine contractions,38 with quinine
having a significant side effect of possible
liver toxicity and congenital abnormali-
ties in the unborn fetus.
Alcohol abuse was evident throughout
Frida’s adult life and, at various times,
drug abuse as well. In 1945, she was
drinking alcohol throughout each day
and became addicted to pain medica-
tions.6 In 1946, following her unsuccess-
ful spinal fusion in New York City, she
relied more and more on morphine
and Seconal (Valeant Pharmaceuticals,
Laval, Quebec, Canada), which she
obtained legally and illegally.13 Seconal is
a barbiturate often used to calm patients
prior to surgery.
Besides a history of depression, alcohol
abuse, and drug abuse, Frida may have
been the victim of sexual abuse during
her childhood. It is purported that Fri-
6 f Physical
January 2017 Therapy Volume 97 Number 1
da’s first sexual experience was with a
female teacher at her school, when she
was only 13 years of age.39 Other hints of
sexual abuse at the hands of her father
have been suggested.30 A systematic
review and meta-analysis by Paras et al40
showed that sexual abuse is associated
with a lifetime diagnosis of nonspecific
chronic pain and other somatic disor-
ders, such as gastrointestinal disorders,
psychogenic seizures, and chronic pelvic
pain.
Frida’s paintings, so often self-portraits,
may have been a manifestation of a dis-
sociative disorder.41 Dissociation repre-
sents a mental break from reality, com-
monly occurring following a traumatic
incident. Feldman41 noted that Frida
often painted dual images of herself on
the canvas— one who appeared vigorous
and intact, while the other appeared bro-
ken and in pain. Alternatively, Reisner42
purported that a relationship exists
between traumatic experience and nar-
cissistic personality, defining psycholog-
ical trauma as any impression the ner-
vous system cannot dispose of through
associative thinking. Thus, her self-
portraits may have served as a means of
dissipating psychological trauma. While
demonstrated in many of her works, her
experience of pain is quite vivid in The
Little Deer (1946). Although pierced by 9
hunter’s arrows, her face remains impas-
sive and serene. Accordingly, this disso-
ciation was used as a means to separate
from the pain and emotional stressors
of her life and completely focus her
thoughts on creating representations of
her experiences of trauma, both past and
present. Another example of this is in
her 1946 painting Tree of Hope, Keep
Firm, where she presents herself as
2 images: a bedridden postoperative
patient and a healthy, confident, and
well-groomed young woman. Conaty43
highlighted the fact that Frida makes
direct eye contact with the viewer in her
work, suggesting that by this technique
she rejects pity for her illness and main-
tains a position of power.
Conclusion
Ultimately, Frida Kahlo experienced “a
perfect storm” of predisposing, contrib-
uting, and causative factors that led to
her complex medical condition. Her
Volume 97  Number 1  Physical Therapy  95
Frida Kahlo
death, which occurred only a year fol-
lowing amputation of her right lower
limb, was attributed to a pulmonary
embolism; however, at least one source
reckoned suicide more likely.6 Yet, it is
how she chose to live life, not her death,
for which she is remembered. Her
strength of character led her to manage
her condition and live her life with pur-
pose and dignity. Her paintings provide a
unique and personal view of chronic
pain, which was clearly a catalyst for her
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brilliant catalog of work. As the preva-
lence of chronic pain increases in mod-
ern society,7 a holistic appreciation of
this disease is critical for a skilled and
empathetic approach to management.
Essential to this process is a comprehen-
sion of the patient experience and the
underlying science of the disease pro-
gression. In addition, early conservative
management that utilizes physical ther-
apy as a primary strategy for treatment is
essential in the appropriate care of the
individual with chronic pain. In the case
of Frida Kahlo, a visual narrative provides
insight into her life experience and may
inspire health care providers in their
search to find new ways to prevent or
reduce patient suffering.
Dr Courtney and Mr O’Hearn provided con-
cept/idea/project design. All authors pro-
vided writing. Dr Courtney provided data
analysis, project management, and consul-
tation (including review of manuscript
before submission). Dr Franck also contrib-
uted to generating the idea for this paper.
Dr Courtney is a Fellow of the American
Academy of Orthopaedic Manual Physical
Therapists.
DOI: 10.2522/ptj.20160036
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