Bechterew’s Disease (Ankylosing Spondylitis): Symptoms, Stages, and Treatment

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You wake up with the feeling that your back is stiff, and getting out of bed takes tremendous effort. This isn’t simply fatigue or pain from being immobile — it’s the daily reality for thousands of people living with Bechterew’s disease. The condition known as ankylosing spondylitis often remains invisible for a long time. That’s why we’ll walk you through the first symptoms, how the disease progresses through its various stages, and what modern treatment methods help patients maintain their mobility. If you, too, are struggling with a Bechterew’s disease diagnosis, don’t overlook the role of professional rehabilitation. We at the PhysioArt Center for Physiotherapy and Rehabilitation – Sofia are here to help.

Bechterew’s disease or ankylosing spondylitis

Bechterew’s disease is known in medical circles as ankylosing spondylitis. It is a chronic inflammatory disease belonging to the group of spondyloarthropathies. Its main characteristic is that it affects the spine and the joints connecting the spine to the pelvis (the sacroiliac joints). The inflammatory process leads to pain and stiffness, and in more advanced stages it can cause vertebral fusion (ankylosis) — one of the well-documented ankylosing spondylitis causes of the characteristic stooped posture, along with restricted movement. Bechterew’s syndrome is an autoimmune disease, meaning the immune system mistakenly attacks the body’s own tissues — in this case, the joints and ligaments of the spine.

Although the exact cause of Bechterew’s disease isn’t fully understood, there is a strong genetic predisposition linked to the presence of the HLA-B27 gene. The antigen is found in around 90–95% of patients with this condition. Of course, not every carrier of this gene develops the disease. Factors such as past infections and environmental influences play a role in triggering it.

Information from the Johns Hopkins Arthritis Center confirms that Bechterew’s disease usually begins in young people, with the peak onset of first symptoms occurring between the ages of 20 and 30. Approximately 80% of patients with ankylosing spondylitis (AS) develop symptoms by age 30, while only about 5% first develop the disease at age 45 or older. Bechterew’s disease is less common in women, with statistics showing a ratio of roughly 2:1 in favor of men.

What Is ankylosing spondylitis? – Understanding the term “spondylitis”

To better understand the nature of the disease, it helps to look at the term ankylosing spondylitis itself. The word spondylitis comes from Greek, where spondylos means vertebra, and the suffix -itis is used in medicine to denote inflammation. Spondylitis therefore literally means inflammation of the vertebrae. This inflammation is at the root of the pain and stiffness that patients experience.

The word ankylosing describes the end result of the chronic inflammation. This term is also of Greek origin and translates as stiff or fused. It refers to the processes of ossification, hardening, and fusion.

Over time, the body tries to heal from the inflammation by forming new bone tissue. This process, called calcification and ossification, can lead to fusion of individual vertebrae, which severely limits the flexibility of the spine. The process most often begins in the sacroiliac joints. These joints bear the entire weight of the upper body, and any inflammation of the sacroiliac joints causes deep, hard-to-localize lower back pain and buttock pain. This blockage of the sacroiliac joints is in fact one of the earliest and most telling signs of the disease.

Distinctive stages of Bechterew’s disease

The progression of Bechterew’s disease can be broadly divided into several stages, although the course of the disease is individual, and not every patient goes through all of them or progresses at the same pace. Distinguishing between these stages helps in choosing appropriate treatment therapies.

In the initial stage, patients experience symptoms such as chronic pain and morning stiffness, but X-rays still show no visible changes in the sacroiliac joints. The pain is inflammatory in nature — it worsens with rest and eases with movement. At this stage, the diagnosis can be established after an MRI scan. Timely, active intervention through physiotherapy can significantly slow the progression.

The second stage is characterized by X-ray-visible changes in the sacroiliac joints (sacroiliitis). The inflammation may spread upward along the spine. Pain and stiffness become more constant, and bony bridges (syndesmophytes) begin to form between the vertebrae. At this stage, maintaining flexibility and proper posture through specialized exercises becomes absolutely essential in order to counteract the spine’s tendency to “stiffen.”

In the advanced stages of Bechterew’s disease, significant fusion of the vertebrae occurs. The spine loses its flexibility, which can lead to a fixed, stooped posture. At this stage, pain may paradoxically decrease as the inflammatory process subsides — but this comes at the cost of severely limited mobility. Even once fusion has occurred, physiotherapy remains important for maintaining overall physical condition.

First symptoms of Bechterew’s disease

Early recognition of the characteristic ankylosing spondylitis symptoms is the first step toward taking control of the disease. They are often mistaken for ordinary, mechanical back pain, which delays an accurate diagnosis by years. The key distinguishing feature is the nature of the pain. Unlike a herniated disc or a muscle strain, the pain of ankylosing spondylitis is inflammatory in nature.

The typical early symptoms of Bechterew’s disease include:

• Chronic pain and stiffness in the lower back and buttocks — This is typically described as dull, deep, bilateral pain associated with ankylosing spondylitis, resulting from inflammation of the sacroiliac joints.
  
• Pain that improves with movement rather than rest — This is a key indicator. If you have Bechterew’s disease, you’ll feel better when you’re active and worse after lying down or sitting for extended periods.
  
• Morning stiffness — Stiffness is most pronounced in the morning after waking up or after a prolonged period of immobility. It typically lasts more than 30 minutes and gradually eases after moving around and taking a warm shower.
  
• Nighttime pain — Many people with Bechterew’s disease wake up during the second half of the night because of pain that forces them to get up and move around.
  
• Fatigue and a sense of exhaustion — Significant, unexplained fatigue is a common symptom linked to the chronic inflammation in the body. This exhaustion doesn’t go away even after a full night’s sleep.

Beyond these core symptoms of ankylosing spondylitis, the disease can also affect other parts of the body. It can cause heel pain (plantar fasciitis or Achilles tendinitis), pain and swelling in peripheral joints (knees, ankles), and inflammation of the eyes (uveitis), which presents with redness, pain, and light sensitivity.

How Is Bechterew’s disease diagnosed?

The diagnostic process is complex and requires combining several different methods, since there’s no single test that can confirm the diagnosis with 100% certainty. When a patient presents with chronic back pain of an inflammatory nature, the doctor (usually a rheumatologist) will take several steps to confirm the diagnosis.

The first step is taking a detailed medical history and performing a physical examination. The doctor will ask about the nature of the pain, when it occurs, what relieves it, whether you have morning stiffness, and whether you have other symptoms such as fatigue or pain in other joints. During the exam, the doctor will assess the spine’s range of motion in different directions, check for tenderness in the sacroiliac joints, and measure chest expansion during breathing.

Laboratory tests are also required to help diagnose Bechterew’s disease. These include blood tests for markers of inflammation such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). These markers are often elevated, but not always. A genetic test for the HLA-B27 antigen is also performed.

MRI diagnostics are the gold standard for confirming Bechterew’s disease. Standard X-rays of the pelvis and spine can reveal characteristic changes in the sacroiliac joints (sacroiliitis) and, later on, the formation of syndesmophytes. In the early stages, however, X-rays may appear completely normal. In these cases, magnetic resonance imaging is indispensable for detecting active inflammation long before structural damage occurs.

Once the rheumatologist confirms the diagnosis, the next and most important step is developing a rehabilitation plan. At the PhysioArt Center for Physiotherapy and Rehabilitation, we design an individualized program tailored to your condition.

How long can you live with Bechterew’s disease?

One of the first and most worrying questions that comes up after a diagnosis is: How long can you live with Bechterew’s disease? Let’s put those fears to rest right away. Thanks to advances in medicine and modern treatment approaches, the outlook today is far better than it used to be. The focus of disease management has shifted from mere survival toward maintaining a high quality of life, functionality, and the ability to work.

Many people with ankylosing spondylitis continue to work full-time throughout their entire careers. This depends on the severity of the disease, the nature of the job, and, above all, the patient’s commitment to the treatment process.

Appropriate treatment for Bechterew’s disease

Treatment for Bechterew’s disease is comprehensive and has two main goals: relieving symptoms (pain and stiffness) and slowing or halting disease progression to prevent damage. The approach is strictly individualized and is determined by the stage of the disease, the activity of the inflammatory process, and the patient’s overall condition.

Medication-based treatment for Bechterew’s disease typically starts with nonsteroidal anti-inflammatory drugs (NSAIDs). If these aren’t effective enough, or if there are contraindications to their use, treatment moves on to biologic medications. Other medications are sometimes used as well, and taking vitamins for Bechterew’s disease — especially vitamin D and calcium — is important for preventing osteoporosis.

Taking medication to treat Bechterew’s disease addresses only one side of the problem — the inflammation. The other, equally important side is the loss of movement, poor posture, and muscle imbalance. This is where rehabilitation and physiotherapy come in. Without active movement and specialized therapies, even the best medications for Bechterew’s disease can’t prevent the progressive restriction of movement.

Are exercises recommended for Bechterew’s disease?

The answer is a definite yes, with one very important caveat: this isn’t just about general physical activity, but about a targeted, professionally guided program. Exercise for Bechterew’s disease isn’t merely a recommendation — it’s a core treatment method. Kinesitherapy (treatment through movement) is absolutely essential and needs to become a daily habit. Its goal is to combat the disease’s main consequences: stiffness, reduced range of motion, poor posture, and muscle weakening.

For optimal results, at the PhysioArt Center for Physiotherapy and Rehabilitation we combine kinesitherapy with equipment-based physiotherapy. Magnetotherapy and ultrasound therapy are used in treatment plans because of their proven anti-inflammatory and pain-relieving effects. TENS therapy may also be applied — transcutaneous electrical nerve stimulation likewise helps block pain signals.

Treatment for ankylosing spondylitis at PhysioArt, Sofia

Our treatment for ankylosing spondylitis is built around one rule: medication can suppress the inflammation, but only movement can save the spine from stiffening. Bechterew’s disease is a progressive autoimmune challenge that requires a comprehensive, strictly individualized approach. That’s why we tailor our approach to each patient’s needs, combining modern equipment-based physiotherapy with kinesitherapy.

• Kinesitherapy — Focused on strengthening the core musculature, maintaining mobility, and performing specialized breathing exercises.
  
• Low-frequency magnetic field therapy — Penetrates deep into the joints, stimulates tissue recovery, and has a powerful anti-inflammatory effect.
  
• Ultrasound therapy — Provides a micro-massage effect and improves the elasticity of hardened connective tissue around the vertebrae.
  
• TENS therapy — Acts as a shield against discomfort by blocking pain signals to the brain and relaxing tense muscles.

Foods to avoid with Bechterew’s disease

At PhysioArt, Sofia, we always advise our patients to view the fight against ankylosing spondylitis as a combination of factors. While there’s no specific diet for Bechterew’s disease that cures the condition, growing evidence suggests that diet can influence inflammation levels in the body. The idea is to eat foods with anti-inflammatory properties and avoid those that can intensify the inflammatory process.

Foods that are best limited include highly processed foods high in sugar, refined carbohydrates (white bread, white pasta), and saturated or trans fats. Excessive consumption of red meat and fried foods can also contribute to inflammatory processes.

On the other hand, the diet should ideally be rich in fruits, vegetables, whole grains, and healthy fats. Foods rich in omega-3 fatty acids have a proven anti-inflammatory effect. These include fatty fish (salmon, mackerel, sardines), flaxseed, chia, and walnuts. Spices such as turmeric and ginger are also known for their anti-inflammatory properties.

In conclusion, treating Bechterew’s disease requires a proactive, multifaceted approach in which you’re the main participant. While medication controls the inflammation, the key to preserving mobility, function, and quality of life is in your own hands, and it’s called targeted physiotherapy. Daily exercise, combined with the modern possibilities of equipment-based physiotherapy, is the most powerful tool you have to fight stiffness and live a full life.

Don’t walk this path alone! The team at the PhysioArt Center for Physiotherapy and Rehabilitation is here to support you and help you live a full and free life. Contact us: https://physioart-bg.com/en/contacts/

This article is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult your doctor or other qualified healthcare professional with any questions or concerns regarding your health.

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