University of Wisconsin–Milwaukee



Entheses and Activities: The Effects of Entheseal Change for Individuals from the Milwaukee County Institutional Grounds Population(Edited Title)SAA PaperJessica SkinnerIntroduction(Title Slide Slide 2)The ability to read the marks of life lived on the human skeleton can provide insight into identity and life experience, improve the life history understanding of a population, and illustrate the individualism of the human condition. (Slide 3) Often, osteological remains represent one of the very few links we retain between the present and individuals or populations of the past. It is for this reason that the methods of osteological investigation are continually evolving to better represent these individuals with whom we have been entrusted. This enterprise is at the core of the work of the Milwaukee County Poor Farm Cemetery Project. In line with that project, the purpose of this study was to further the work of representing and contextualizing the life experiences of those interred in the cemetery through entheseal change analysis using a replicable non-metric scoring method and 3D geometric morphometric analysis. In addition this project validated a multi-factorial approach to understanding osteological change through the insertion sites of the primary rotator cuff muscles. This multi-factorial approach will enable a more accurate discussion about activity by beginning the process of distinguishing activity related changes from other changes. It will also add depth to discussion about pathology by revealing the full extent to which some disorders affect non-adjacent areas of the body. Theoretical FrameworkThe analysis of musculoskeletal dynamics for the purposes of determining past life activities and histories is a continuously expanding aspect of the field of osteology, particularly in recent years. The roots of this work, however, occur relatively early. Julius Wolff, in 1892, states that (slide 4) “Every change in the form and function of bone or of their function alone is followed by certain definite changes in their internal architecture, and equally definite alteration in their external conformation in accordance with mathematical laws.” (Wolff 1892, 1986:23). This concept is a cornerstone of analyzing musculoskeletal dynamics and has given rise to other important principles regarding bone’s reaction to external and internal stressors. These principals include the idea that various stimuli, including mechanical ones, can cause bone formation or resorption, and that these reactions are not coupled biologically, but can act as separate agents (Frost 2003:176). Closely related to this is the assertion that the internal architecture of trabecular bone undergoes adaptive changes, which are followed by secondary changes to the external cortical bone (Stedman 2000), enabling a set of specific biogenic processes to be attributed to landmark formation. These concepts create a framework in which to describe and explain the osteological changes observed at muscle attachment sites, or entheses. Entheses and Entheseal Change (Slide 5) Entheses are defined as the areas where a tendon, capsule, or ligament attaches to bone (Villotte 2012:3). There are two main types of entheses: fibrous entheses, which attach soft tissues to the bone directly or via the periosteum, and fibrocartilaginous entheses which interface with the bone in four zones. (Slide 6) (Villotte 2012:3). Fibrocartilaginous entheses are distinguished by four histological zones and a tidemark, which is a regular calcification front that separates the calcified and uncalcified fibrocartilage. (Slide 7) The tidemark (TM) between the calcified and uncalcified zones of articular cartilage (AC) is continuous with that at the insertion of the tendon. (Benjamin et al., 1986; Cooper and Misol, 1970) The cellular interactions between the tissues of bone, tendon, ligament, and cartilage at these attachment sites result in changes of the osseous structure both in terms of general size and rugosity as well as within the surface structure of the cortical bone. The changes made to the cortical bone are observable in the form of bone deposition, erosion, and porosity. The visibility of this marked and observable change to the areas of bone known to be associated with specific musculature has spurred the investigation of attachment sites in juxtaposition with the known biomechanical stressors attributed to various activities (Hawkey and Merbs 1995). This musculoskeletal stress marker research has been aimed at developing a widely accepted method of determining a direct correlation between markers on bone and past life activities and life histories. Counter to this goal, disparities of interpretation arise when conducting these analyses due to the dynamic nature of living bone and its multivariate interactions with muscular and connective tissues. The etiology of these changes has many underliers such as age, sex, pathology, physical activity, and individual variation, which need to be identified in order to fully evaluate entheseal change, but which sometimes overlap, making it difficult for researchers to make clear distinctions (Cardoso and Henderson 2010). In addition, a need for increased standardization and improved analytical approaches for landmark scoring and interpretation is evident throughout the literature (Peterson and Merbs 1998). Despite these challenges, many recent works have begun to build a stronger framework in which to interpret entheseal change. Cardoso and Henderson call for an integration of age related changes into the discussion about entheseal change, which requires standardized and replicable age estimation methods (Cardoso and Henderson 2012). Accurate estimation of the relative osteological age of the individual being examined is crucial to the process of connecting age to skeletal traits and conditions. A standardized method will prove useful to answering many important osteological questions (White et al 2011). Particularly within the study of entheseal change, accounting for the fact that “Aging results in alterations in the dynamics of bone cell populations, resulting in the uncoupling of the normal process of bone resorption and formation, as well changes in bone architecture.” (Kiebzak 1991:178) is key. The resulting elevated levels of entheseal change expression associated with age as reflected in muscle attachment sites affect the impact of biomechanical loading and change what inferences can be made about labor intensity (Niinimaki 2011). (Slide 8) In addition, data gained from clinical studies of muscle, bone and joint interactions in living individuals reveals a connection between localized arthropathy (or joint inflammation) and enthesopathy of synovial joints, or capsule-type joints at various uncoupled points throughout the same individual (McGonagle et al 1998, Zytoon, et al 2014). Periostalgia (noted in archaeological contexts as periostitis), or the inflammation of periosteal tissue, has also been found in clinical contexts to be associated with increased entheseal change, as observed by McGonagle (Slide 9) “On MRI, the [spondyloarthropathies] are associated with extensive inflammatory changes at a considerable distance from the enthesis, illustrated at the plantar fascia and Achilles’ tendon where enthesitis is associated with marked osteitis or synovitis in the immediately adjacent tissues.” (McGonagle 2005: 59). These MRI diagnostics have prompted researchers to test for the effect of concurrent osteopathologies on entheseal change. In addition, more accurate and expressive morphometric analysis is also available as evidenced by Nolder (2013). These advancements create a multifaceted environment in which entheseal change may be studied.Background(Slide 10) The Milwaukee County Poor Farm Cemetery is located in Wauwatosa, Wisconsin. The excavated cemetery is one of four burial locations situated on the Milwaukee County Institution Grounds. (Richards 1997:11). This cemetery was used from 1882 to 1925. (Slide 11) Based on institution records and historical data, it is likely that individuals buried here, particularly males, would have engaged in physical labor during a substantial portion of adult life. The Annual Report of the County Farm and Almshouse: 1896 demonstrates this: of the 592 almshouse occupants, the two most represented occupations were laborers (270 individuals) and farmers (83 individuals) (Richards 1997:69). (Slide 12) These individuals would have partaken in intensive labor in their occupations prior to entering and while residing at the almshouse, participating in activities to sustain the running of the grounds and almshouse. This lifelong engagement in physical activity placed a great deal of strain on the condition of the physical body.Methods (Slide 13)A sample of 40 osteologically estimated males, determined using standardized non-metric assessment methods (On Slide 14) from the 2013 population was divided into age ranges in increments of 5 years based on mean osteological age. These ages ranged from 30-55+ years, each mean estimated using standardized methods. (On Slide 14) Subadults and females were excluded from this study due to relatively small representation within the 2013 population. The use of five-year age ranges enabled a clearer gradient of age groups and enhanced the delineation of age affected factors of bone change. The muscle insertion sites of the primary rotator cuff muscles: subscapularis, supraspinatus, infraspinatus, and teres minor (slide 15) were selected for this study due to the high impact of many labor-intensive activities on these muscles. Osteopathology was also assessed for the individuals in the 2013 population, using standardized methods. Disease categories that may influence osteological change, particularly fibrocartilaginous joint change, were noted and compared with non-metric visual entheseal change data. These categories are broken down into four groups: irregular bone deposition, joint pathology, infection and inflammation, and trauma. The non-metric entheseal change analysis took place separately from collection of age and pathology data to avoid bias. The left side was used in this analysis as the preferred standard. (slide 16) Visual and statistical 3D geometric morphometric landmark data was collected using 3D data capture with a Microscribe 3D digitizer. This data was analyzed using open sourced statistical software. Each enthesis was recorded separately and placed within a three dimensional space for comparison, allowing for a Generalized Procrustes analysis, allometric plotting, and testing of morphologic disparities. An example of the three dimensional digitized enthesis is represented in the slide. Ordinal regression was performed on the composite scores of the left side for the subscapularis, supraspinatus, infraspinatus, and teres minor entheses. The composite score was designated as the dependent variable with age and pathology score as the covariates. ResultsThe effect of ageThe individuals (n=40) selected for the preliminary test on the effect of age had a normal age distribution (range 30-55+ years, mean=42.81 years, standard deviation 8.03). For most entheses, increased scores were associated with increased age. Statistical significance (<0.005) was observed in relation to the effect of age in association with subscapularis, supraspinatus, infraspinatus, and teres minor. The increase of entheseal change scores in conjunction with increased ages can be observed in the plots shown (slides 17 and 18). Though further analysis is required with an increased sample size, these results serve to confirm previous studies (Mariotti et al., 2004, 2007; Milella et al., 2012) that have connected age with differential deposition of bone and differences in the entheseal change process. The preliminary results regarding geomorphometric shape in concurrence with age illustrate a tendency for entheseal border change with increased age at the subscapularis. This is seen in the shape comparison on slide 17. This contributes to the evidence of age’s effect on entheseal change.The effect of concurrent pathologyIn order to test the effects of infection and inflammation on entheseal change, ordinal regression was also conducted on the sample with this pathology category as the covariate. Within this category increased entheseal change scores are associated with positive identification of irregular osteological deposition. Entheseal change scores are plotted against irregular bone deposition, joint disorder, infection and inflammation presence. (Tables on slides 20 and 21)DiscussionThese results not only assist in the validation of multi-level analyses of entheseal change, but also provide a glimpse into the daily lives and conditions of these individuals, beyond a statement about repetitive activity. The social lives of those buried in the cemetery and the physical manifestation of those lives had a great effect on the quality of life, physical well-being, relationships, and place in the world experienced by these individuals, enough so that we are able to see that hardship within their osteological change.ConclusionsThe preliminary data gained from this research illustrate that the goal of reproducing the new non-metric entheseal scoring method developed by Henderson and Villotte was partially achieved, and that further delineating and understanding the connection between age and entheseal change is possible. Though additional tests are required to illustrate this connection more definitively, a tendency for entheseal change to become more pronounced with advanced age is evident. These data also illustrate that a correlation can be determined between concurrent pathology of an individual and a relative rate of entheseal change, therefore underscoring the implications of systemic pathology and the importance of considering that bone is one of many connective tissue organs that interact on many levels; this has important implications for enthesopathy and the determination of past life activities. These findings do not determine one source of entheseal change motivation; rather, they highlight the importance of a multi-level approach to understanding entheseal change and illustrate that further investigation and experimentation are required to fully understand the processes that inscribe the experiences of life on each individual. 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