Frida Kahlo: Portrait of Chronic Pain
Physical Therapy, Volume 97, Issue 1, 1 January 2017, Pages 90–96,https://doi.org/10.2522/ptj.20160036
Published: 25 August 2016
The artist Magdalena Carmen Frieda Kahlo y Calderón was born in a suburb of Mexico City on July 6, 1907.6 As a feminist, political activist, and painter, Frida Kahlo was truly a revolutionary born during a revolutionary period of Mexican history. Although Mexico’s artistic focus was often directed toward European history and culture at the turn of century, the 1910 Mexican Revolution produced a significant transformation in Mexican self-identity.6 Escape from European traditions allowed Mexico to reinvent itself and to rewrite its history, where a new understanding of Mexican culture was developing. Intelligent and naturally gregarious, it is likely that Frida Kahlo thrived in this environment of radical nationalism, where creativity and original thinking were encouraged. Frida Kahlo is arguably one of the most influential 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 historians and biographers have detailed these life events and analyzed her work, less is understood about the neurophysiological basis of her condition.
Frida Kahlo’s journey into chronic pain.
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 efficient at delivering their message. Eventually, 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 alleviate the suffering. In recent years, science has made great strides in understanding not only the pathophysiology of chronic pain but also the various factors that may contribute to aberrant pain processing. Thus, when knowledgeable on the topic, researchers and practitioners alike are beginning to more readily identify 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.9,10Individuals with chronic pain may demonstrate multiple areas of pain, heightened intensity of symptoms, spread of symptoms, and seemingly unrelated sensory and neurovascular phenomena.11 How these signs and symptoms are interpreted is critical 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 marginalizing experience. By understanding the 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 science of chronic pain.
A Childhood of Trauma
Frida Contracts Poliomyelitis
At age 6 years, Frida contracted poliomyelitis, which is more commonly known as polio. Polio is a crippling and potentially deadly infectious disease caused by the poliovirus. Her contraction of the disease coincided with the first large outbreak in the United States in 1916, with more than 27,000 cases and more than 6,000 deaths.12Frida remembered experiencing 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 medical records indicate that her limb failed to develop compared with her unaffected limb.14 This leg-length discrepancy 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 approximately 15 or more years,16 which suggests 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 common in people with post-polio syndrome, but often is rated as moderate to severe and frequently occurs in many locations around the body.18 Using the Nottingham Health Profile questionnaire, individuals with post-polio syndrome were found to have higher levels of distress in the dimensions of energy, physical 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 syndrome are variable and include: (1) degeneration of the enlarged motor units that develop after acute poliomyelitis, (2) a chronic persistent poliovirus infection, 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 vascular insufficiency. Smith et al21 suggested that these vascular changes may relate to sympathetic intermediolateral column damage from the acute poliomyelitis. Regardless of the cause, it is known that Frida ultimately experienced vascular insufficiency, which led to subsequent amputations.14Understanding 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.
Frida Survives a Terrible Streetcar Accident
Despite her childhood illness, Frida grew into a lively, intelligent young girl. She was accepted into the Escuela Nacional Preparatoria, the best educational institution 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 significant trauma, including multiple fractures 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 tissues healed following the accident, it was during this time that the slow insidious 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 complaints following the streetcar accident.6 In later years, while traveling with her husband, Diego Rivera, Frida would consult 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 congenital scoliosis or functional scoliosis ensuing from her leg-length discrepancy, 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 degeneration and pain.15 Dr Eloesser also diagnosed 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. Interestingly, 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 modern 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 system, facilitating aberrant pain processing. Although surgical goals (eg, stabilization) 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 outcome 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 the bed facing away. In this painting, Frida portrays the surgery as a large, jagged 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 spinal surgeries, a spinal fusion of 4 lumbar vertebrae was recommended. During this surgery, bone was harvested from her iliac crest and inserted for the purpose of fusing spinal segments, limiting movement and diminishing pain. The surgery was a failure, and bone infection (ie, osteomyelitis) was induced. The result was a draining, infected wound. Gamble13 noted that it is now known that long spinal fusions are difficult to accomplish in the lumbar spine. In addition, Frida was a heavy smoker, and smoking is a known risk factor for failure of spinal surgery.25 In fact, the rate of nonunion (failure to fuse) was almost doubled in one study of postsurgical outcomes in smokers.26
Frida’s struggle with chronic back pain and failed surgeries is further represented 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 image can be disrupted in people with pain disorders, including low back pain.27The 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 apparent, is the contrast of her broken body and the fortitude displayed in her countenance.
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.
An important factor contributing to Frida’s chronic pain was the very real possibility that she sustained nerve damage during the streetcar accident. In her letters, she intimated, “The sciatic nerve is damaged as well as another nerve…to the genitals.”28She 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 Anatomically, 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 transmit pain and, following injury, may develop abnormal sensitivity and spontaneous activity.29 Ultimately, the central nervous system may become sensitized and pain easily triggered. The potent imagery in What the Water Gave Me(1938) (Fig. 3) has been interpreted in many ways6,30; however, these images also may represent, in part, her chronic right leg pain. In this painting, the artist’s limbs are partially immersed in a bath. Over her right limb is a volcano with lava streaming from its cone, potentially representing the unpredictable burning nature of her pain. Out of the volcano protrudes a modern skyscraper, having no effect on the flow of lava, perhaps signifying the failure of modern health care at the time to provide relief.13 People with neuropathic pain often complain of spontaneous pain, described as shooting and burning,31 and experienced 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 that the impulse may fire without stimulus, thus generating spontaneous pain.
What the Water Gave Me, 1938 (oil on canvas), Kahlo, Frida (1907–1954)/Christie’s Images/Photo © Christie’s Images/Bridgeman Images/Permission Artists Rights Society, New York, New York.
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 elicited with light touch of the skin, indicating 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. Allodynia 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 recalcitrant and very difficult to treat,29 particularly as it is associated with hypersensitivity 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 that Frida’s leg pain would have worsened and expanded beyond the original distribution of pain. With the severity of her injuries, this likely occurred. It is clear that Frida suffered tremendously from this aspect of her condition.
A Slowly Dying Limb
While in San Francisco, Frida’s signs of vascular insufficiency were addressed medically.13 She developed a trophic ulcer on her right foot, which would progress in the following years, eventually resulting in excision of 5 phalanges in 1934. Vascularity continued to be an issue, and gaining wound closure was difficult. In What the Water Gave Me (Fig. 3), Frida portrays her right foot as deformed, with a jagged unhealed wound. In 1936, the sesamoids of her foot were excised and a sympathectomy was performed for the purpose of regaining circulation.13Sympathectomy is a surgical ablation performed by open interruption of the nerves of the sympathetic chain near the spinal cord. It has been used medically for varying reasons, both for relief of pain33 and to promote vasodilation.34 In Frida’s case, there may have been neurovascular damage when her right foot was crushed. Alternatively, vascular compromise has been identified as one of the sequelae of post-polio syndrome.20 By 1944, she was living with unremitting pain,13 and more than one medical expert has suggested that she may have transitioned to complex regional pain syndrome I or II,14,35 a form of severe chronic pain, typically affecting one of the limbs, that occurs with or without nerve injury. In 1953, Frida required amputation of her right lower limb due to gangrene.14
Considering the numerous physical and emotional traumas in her life, it is perhaps not surprising that she struggled with mental illness. Frida was a charismatic 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 miscarriages, and the recurrent infidelities of her husband, Diego Rivera, would serve as triggers for these psychological disruptions. Heightened emotional or psychological stress may contribute to the chronic pain experience.37 It is likely that Frida had mixed feelings about having 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 stimulating uterine contractions,38 with quinine having a significant side effect of possible liver toxicity and congenital abnormalities 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 medications.6 In 1946, following her unsuccessful 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.13Seconal 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 Frida’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 disorders, such as gastrointestinal disorders, psychogenic seizures, and chronic pelvic pain.
Frida’s paintings, so often self-portraits, may have been a manifestation of a dissociative disorder.41 Dissociation represents a mental break from reality, commonly 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 broken and in pain. Alternatively, Reisner42purported that a relationship exists between traumatic experience and narcissistic personality, defining psychological trauma as any impression the nervous 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 impassive and serene. Accordingly, this dissociation 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 maintains a position of power.
Ultimately, Frida Kahlo experienced “a perfect storm” of predisposing, contributing, and causative factors that led to her complex medical condition. Her death, which occurred only a year following 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 purpose and dignity. Her paintings provide a unique and personal view of chronic pain, which was clearly a catalyst for her brilliant catalog of work. As the prevalence of chronic pain increases in modern society,7 a holistic appreciation of this disease is critical for a skilled and empathetic approach to management. Essential to this process is a comprehension of the patient experience and the underlying science of the disease progression. In addition, early conservative management that utilizes physical therapy 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.
© 2017 American Physical Therapy Association