FREIBURG — Sometimes the stabbing pain was almost unbearable. For six years, Susanne Ganter has been tormented by nerve pain in her face. It is a pain that keeps returning. Every few seconds it shoots through her, causing her to panic and sending her back to the doctor again and again. “There had to be a cause,” says the 67-year-old. “I could show exactly where the pain was coming from.”
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It all started with a dental appointment where she had a bridge fitted. At first, there was only pressure, then it turned into sharp, stabbing pain. The dentist didn’t believe her, so she switched practices. The next dentist only gave her a mouthguard to stop grinding her teeth, but the pain persisted.
What began as a minor dental procedure became a neverending ordeal. Over the years, numerous procedures followed. Ganter underwent several root canals, then a dentist extracted the painful tooth, and she received first a temporary implant, then a permanent one. In addition, there were countless X-rays, accompanying therapies such as massages, physiotherapy, relaxation exercises, and finally costly complementary treatments with an osteopath and craniosacral therapy.
“At some point,” says Ganter, “you’re ready to do anything to finally get rid of the pain.”
Chronic pain is defined as pain that lasts longer than three months. In almost half of all cases, it is back pain, followed by knee pain and headaches. Osteoarthritis and herniated discs are the most common causes. In some cases, the pain is constant, while in others, like Susanne Ganter’s, it returns again and again.
False alarm
Whether it is a sore tooth, a broken finger, or an inflamed appendix, pain pushes everything else into the background. This is useful, because acute pain is a vital warning signal from the body: attention, there is an injury, take care, prevent further damage. Pain even tells us where the danger lies. Normally, it subsides once the threat is gone, once the broken finger has healed or the infected tooth or appendix has been treated. But sometimes the pain lingers.
It becomes independent, detached from its cause, and loses its biological function, like a smoke detector that keeps going off for no reason. The insidious thing is that sufferers continue to experience the pain as acute; the body’s own alarm system stays on red alert. Unlike the other human senses, the body cannot get used to pain. On the contrary, it keeps both body and mind under constant stress. Despair grows. People’s daily lives become restricted, and they often find no satisfactory answers from doctors.
Susanne Ganter had a similar experience. “I could feel exactly which tooth hurt,” she says. The petite woman with shoulder-length gray-blonde hair sits at a conference table in the interdisciplinary pain center at the Freiburg University Hospital and repeatedly points to a spot in her upper jaw, above the right canine. She was convinced that something was wrong there. That is why she kept seeking more dental treatment. But none of it helped, and no one could find the cause.
Pain memory
But how can pain persist when no cause can be found? The answer lies in the nervous system and the way the brain processes and evaluates pain stimuli. In the body, nerve fibers are responsible for sensory perception. Nerve endings detect external stimuli such as heat, cold, or pressure and convert them into electrical signals. If these receptors are activated repeatedly, their threshold lowers, and the nerve sends signals more quickly.
For electrical signals to be felt as pain, they must travel through the spinal cord to the brain. The spinal cord acts as a filter, checking whether the signal is strong enough to be passed on. It also recognizes how often a stimulus has already been transmitted from a particular location. If the same pain pathways are activated repeatedly, they grow stronger, like a narrow trail that turns into a wide road over time. This is how pain memory develops. Eventually, even a mild stimulus can trigger severe pain.
Chronic pain develops first because the nervous system becomes more sensitive to persistent stimuli. Doctors call this the biological component. But the experience of pain also depends on previous experiences, emotional state, stress, and sleep. This is where another crucial mechanism comes in: how the brain interprets pain.
The matrix
When a pain signal reaches the brain, the information is distributed to different regions. There are various pain centers in the brain. “We speak of a pain matrix,” says Frank Petzke, who heads the interdisciplinary pain medicine department at the University Medical Center Göttingen. This matrix includes, among other areas, the prefrontal cortex and the limbic system, both of which are key for learning. They compare the stimulus with past experiences and evaluate it emotionally. Is the pain familiar and therefore manageable, or does it trigger fear, stress, and panic? Could it even awaken old childhood traumas?
Several relatives in Susanne Ganter’s family had already suffered from dental problems. So she became anxious when her own dental issues began. Large studies show that in chronic pain, the brain regions responsible for cognitive and emotional processing are more active. And emotions like fear can, in turn, amplify pain.
Chronic pain cannot be explained by biology alone.
Chronic pain cannot be explained by biology alone, such as a sprained ankle, lumbago, or an injured nerve. It is always tied to how one experiences pain emotionally, for instance, whether one fears never being able to walk or work again.
Frank Petzke emphasizes this point to patients and in medical training: “We now know that every pain arises from the interaction of biology, psychology, and social circumstances.” The intensity of pain can therefore be detached from its purely biological cause. “Only with this understanding can we explain why, for example, some people with nerve damage from diabetes feel no pain, while others experience intense burning.”
Powerful minds
The influence of the psyche is significant in several ways. Chronic pain affects mood, dominates everyday life, and leads sufferers to withdraw socially. Pain patients are more likely to experience depression, anxiety disorders, and post-traumatic stress. Here, psychological problems can be both a result and a cause. Mental illness can increase the risk of pain becoming chronic in the first place and can worsen its progression.
Even daily stresses that weigh on mental health can contribute to chronicity. A person who feels pressured because they often have to call in sick or because of financial strain may find that their pain becomes more entrenched. If rest does not bring improvement, they may withdraw further, centering their life entirely on pain.
Because of their pain, many sufferers are forced to cut back on work, leading to repeated sick leave, first for a few days, then for longer periods, sometimes ending in early retirement. The German Pain Society estimates that chronic pain costs around 38 billion euros annually, mostly from related costs such as sick pay, lost working time, and early retirement.
The problem with pills
“We as a society need to understand how the body, mind, and social environment affect us,” says Kristin Kieselbach, head of the interdisciplinary pain center at the Freiburg University Hospital. Especially in chronic pain, the belief persists that painkillers or surgery are the only options. Two-thirds of chronic pain patients receive prescription drugs, sometimes strong opioids, even though their effectiveness is limited. One in two also takes over-the-counter medications like ibuprofen, which only help about one in three people.
“We learn from an early age that pain has a cause and that the doctor will give us medicine to treat it,” says Kieselbach. “But ultimately, we cannot succeed if we treat the biological, psychological, or social aspects in isolation.”
What matters most for effective therapy is the interaction of all factors. That is why interdisciplinary multimodal pain therapy has long been part of official treatment guidelines. In this approach, the patient receives medical, psychotherapeutic, and physical therapy in close coordination. It is recommended after six weeks of persistent pain if conventional treatment brings no relief and there is a high risk that the pain will persist.
Years of suffering
In practice, however, implementation is often difficult. “Most patients who come to us have been suffering from pain for many years,” says Kieselbach. Like Susanne Ganter, many hear about interdisciplinary pain centers only by chance. In Germany, such specialized therapy is available only in hospitals, where patients are treated as inpatients or day patients. It is therefore not easily accessible.
“Too often, pain patients are trapped in a vicious cycle for years and see a doctor too late,” says Petzke. A back pain patient, for example, goes to their family doctor, receives pain medication, and perhaps some physiotherapy. When that fails, the orthopedist orders an MRI, which shows a herniated disc. Yet it is rarely clear whether this is actually causing the pain. Surgery often follows anyway. If the pain persists, the cycle begins again, says Petzke. “Many sufferers are exhausted, disappointed with their doctors, and clinging to any hope.”
General practitioners often lack the time to review long medical histories. In multimodal therapy, however, this is precisely the first step. Before treatment starts, a thorough assessment takes place over the course of a full day. Medical reports are gathered, and patients complete detailed questionnaires covering pain intensity, physical risk factors, and psychological aspects.
“At the pain center, we conduct a 90-minute medical assessment, a one-hour psychological evaluation, a one-hour physiotherapy assessment, and, if needed, a social history review, and examine the patient,” says Kieselbach. Afterward, all therapists issue a joint treatment recommendation.
Learning to live with it
At the University Hospital in Freiburg, around 1,400 people with chronic pain are treated each year. In February, Susanne Ganter was one of them. For four weeks, she followed a structured daily program and joined a group of five other patients. One suffered from severe back pain, another from shoulder pain. “The longer we were together, the more we supported one another, shared tips, and gave honest feedback,” Ganter recalls.
At the start of therapy, the focus is on understanding what chronic pain is, how it develops, and why it feels so real even when no cause can be found. “It is important to us that we are not a ‘pain-go-away’ clinic,” says Kieselbach. “Anyone who comes here cannot expect to be pain-free afterward.”
Still, the treatment can make a huge difference. It is about finding better ways to cope with pain and to lead a life no longer ruled by it.
Patients are given a toolkit to help them reach their personal goals again. Pain specialists call this functional restoration. If the pain also becomes less intense in the process, that is a welcome bonus. Because just as the body has learned to feel pain, it can also unlearn it —both physically and mentally. But that takes time and effort.
Movement and balance
Some steps require courage. For example, patients learn that movement and physical activity, in particular, can ease pain. Many find this counterintuitive and prefer to rest, but exercise as a standalone therapy is actually more effective than medication or psychotherapy. According to treatment guidelines, this approach helps two out of three patients. While the exact mechanisms remain unclear, it is known that movement activates pain-inhibiting nerve pathways in the brain that suppress pain signals in the spinal cord. Exercise also benefits brain regions that regulate emotion in chronic pain patients, which can, for example, reduce anxiety. In contrast, physical inactivity and fear of movement can heighten the perception of pain.
At the clinic, Ganter learned to overcome what is known as fear-avoidance behavior to prevent overexertion. “In physiotherapy, it was about relearning exercises, trusting my body again, and finding the right balance between activity and rest,” she says.
Rest is crucial to avoid overdoing it. And not only in sports: in psychotherapy, Ganter also practiced applying this pacing to her social life. She says she used to try to please everyone: as a wife, mother, businesswoman in her husband’s company, as a friend or hostess. Saying No was hard for her; she preferred to ignore her own needs. But overexertion, both physical and emotional, worsens pain perception. The solution: setting boundaries and not always being available to babysit grandchildren, help out at the shop, or host visitors.
More than six months have passed since her pain therapy. Susanne Ganter can now cope with her pain much better; it has not disappeared completely, but it is no longer unbearable. “I tell myself: it is just my mind that thinks I am in danger and sends false signals.”
Above all, Ganter has learned that she is safe. She knows her body is fine, there is nothing wrong with her tooth. She has learned to stay calm.
