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Musculoskeletal stress markers (MSM):
methodological reflections
Valentina Mariotti, Marco Milella, Maria Giovanna Belcastro
Laboratorio di Bioarcheologia e Osteologia ForenseDipartimento di Biologia Evoluzionistica Sperimentale
Via Selmi, 3 - 40126 Bologna, Italia
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1. Terminology
MSM: Hawkey and Merbs (1995): marks that occur where a muscle, tendonor ligament inserts onto the periosteum and into the ubderlying bony cortex.
Invalidant conditions (fractures,luxations, amputations, etc.)
Some pathologies(DISH, etc.)
age
Type and/or level ofphysical activity
Individual factors(genetics)
Bone architecture
Habitualpostures
Markers of occupational stress(MOS)
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very prominent,but surfacesmooth
not prominent,but surfacerough
evidententhesophyte
very prominentmedial border
smallenthesophyte
enthesophytes,erosions
pitting
??ENTHESOPATHY??
Sardinia,ossuary
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(Mariotti et al., 2004, 2007)
Robusticity : normal surface irregularity or rugosityosteolytic lesion ( OL): presence of pitting or eroded areas
enthesophitic formation ( EF): presence of enthesophytes
MSM(Hawkey and Merbs, 1995)
Robusticity marker : normal reaction to habitual muscle usageseen in its mostextreme expression as sharp ridges, or crests, of bone.
Stress lesion : pitting, or furrow, into the cortex to the degree it superficiallyresembles a lytic lesion.
Ossification exostosis : exostosis, or bony spur.
Pathological
1. denoting an abnormal finding, particularly a morphological alteration
2. resulting from disease(International Dictionary of Medicine and Biology, Whiley and Sons, 1986)
pathological boneresponse to stress.
Enthesopathy
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2. Scoring method
Descriptive standard for evaluation of
type of bone change (ROB, EF, OL)
degree of development
Standardised scoring methodReproducible observationsComparable results
MSMqualitative nature + continuous variation
macroscopic observationsubjectivity
23 entheses ofpostcranial skeleton
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1a 1b 1c 32
1a - slight impression : the surface is practically smooth, even though an oblique line is perceptibleto the touch.
1b low development : the insertion is marked by a line of rugosity.
1c medium development : the line of insertion is marked by obvious rugosity, or there is a slightcrest with smooth surface.
2 - high development : definite crest, possibly discontinuous, but with obvious rugosity.
3 very high development : very raised and rugose crest.
ROBUSTICITY (standard different for each enthesis) (Mariotti et al ., Coll. Antrop., 2007)1 low to medium development
2 high development
3 very high development M. SOLEUS
Interobserver error: about 20%
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ENTESOPATHIES (standard applicable to any enthesis)(Mariotti et al ., Coll. Antropol., 28 (1), 2004)
1 2 3
ENTESOPHYTIC FORMATION (EF)
0 absence
1 - minimal exostosis (4 mm)nr more than 50% of the area isillegible
Interobserver error : about 5%
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OSTEOLYTIC FORMATION (OL)0 - absence
1 - fine porosity (holes 4 mm)nr more than 50% of the area isillegible
1 2 3ba
1 2
1: pitting 2 and 3: erosions
Attention !!!
1
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m.brachioradialis
m.deltoideus
m.lat.dorsii/teres m.
m.pectoralis major
humerus
m.deltoideus
m.pectoralis major trapezoid lig.
conoid lig.
202202costoclavicular lig.
clavicle102001cm.triceps brachii
scapula
OLEFrob.OLEFrob.OLEFrob.OLEFrob.
rightleftrightleftYA/MA/OA/NIM / F / NIYA/MA/OA/NIM / F / NIsex / age
N 33Specimen
Data collecting form
3 I i
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Identification of the factors that influence the expression of MSM3. Interpretation
Difficulty of recognising which factors are responsible for the featureobserved and to which extent, respectively
1. multifactorial etiology (genetic and environmental factors)
age
genetics
diseaseactivity
sex factors
2. monotone bone response to stress (bone production bone resorption)
No biunivocal
correspondencebetweenetiologicalfactors andbone changes
bl h
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living persondry boneMaterial
symptoms, anamnesis,medical tests, evolution of
disease
pattern of bonyalterations
Diagnosis
dynamic prcessstatic situationEvolution
possiblenot possibleSoft tissuesobservation
indirect(x-rays, tomography, etc.)
direct(> resolution)
Bone observation
diseasevariabilityInterestMedicalAnthropologicalApproach
1. Anthropological: study of identified skeletal collections (known age, sex, etc.)
2. Medical: clinical cases of occupational and sports medicine
Possible approaches:
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The Frassetto identified skeletal collections (known age, sex, occupation)(Museum of Anthropology, University of Bologna, Italy)
Sassari (SS Sardinia, Italy), end of 19 th -beginning of 20 th c.
(pathological specimens or specimens with uncertain age excluded)
486
212
274
Tot
Tot
Females
Males
163155168
626684
1018984
> 50(OA)
36-50(MA)
20-35(YA)
occupation known: 173 M (39% farmers)
125 F (95% housewives)
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entheses grouped into six FUNCTIONAL COMPLEXESupper limb: shoulder, elbow -flexion/extension,forearm-pronation/supinationlower limb: hip, knee, foot
Mean score : mean degree of development of theentheses of each functional complex
METHODSMales
L RYA MA OA
Females
L RYA MA OA
frequencies (%) for each ENTHESIS :
ROB: grades 1, 2+3 (low-medium / high development)EF: grades 0+1, 2+3 (absence / presence)
OL: grades 0, 1, 2+3 (absence / pitting / erosions)
- differences among age
classes in M and Frespectively: p ( 2)
- differences betweensexes or sides withineach age class: p (Fisher)
-relation age/score:Spearman R and
relative p value-side differences:Wilcoxon matched pairstest
- sex and activitydifferences: Mann-Whitney U test
ROBUSTICITY BILATERAL ASYMMETRY
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0,4420,3270,5070,3070,0140,790foot
0,5480,1720,3750,8080,5130,557knee
0,1840,2650,0290,2450,8260,638hip0,4920,0580,0710,7120,1640,818lower limb0,1720,0200,1140,5100,1120,038forearm
0,0010,0190,0280,9940,5040,980elbow0,0000,0000,0010,8950,0410,000shoulder
0,0000,0000,0000,6280,0690,000upper limbpppppp
N=86-96N=70-82N=61-75N=50-61N=51-63N=59-75
OAMA YAOAMA YA
MFL / R
ROBUSTICITY BILATERAL ASYMMETRY(Wilcoxon matched pairs test)
1. bilateral asymmetry in both sexes upper limb
2. bilateral asymmetry decreases with age in F, remains stable in M
ROBUSTICITY SEX DIFFERENCES
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ROBUSTICITY SEX DIFFERENCES(Mann-Whitney U test)
2,652,590,0402,211,981,491,40foot2,172,361,921,921,461,42knee2,522,912,162,261,731,75hip2,372,582,052,031,521,51lower limb
1,852,551,561,580,0311,120,93forearmR2,002,430,0261,692,011,491,47elbow2,022,351,901,900,0361,731,61shoulder
0,0321,992,441,771,880,0441,551,46upper limb0,0082,632,812,111,991,541,35foot
2,182,331,881,851,471,38knee2,482,882,162,241,731,66hip
0,0052,372,612,032,011,551,45lower limb
0,0001,852,471,471,500,0211,070,88forearmL2,022,311,731,951,461,44elbow2,012,221,841,761,571,51shoulder
0,0051,982,301,761,771,461,36upper limbpFMpFMpFM
OAMA YAmean score
F>M M>F or F>M M>F
CORRELATION ROB AGE
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CORRELATION ROB - AGE
pM; OA: M>F
Hp: young F worked hard developed entheses in spite of the
young age
lower correlation coefficient with age
Mechanical stress or sex factors?
Frequency of EF (2+3%)
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0,00038,719,04,30,00032,316,94,3Achilles tendon CA
0,8444,03,42,50,1767,12,32,5m.soleus TI0,04613,19,42,60,06212,18,02,5qudriceps tendon TI
0,00119,511,51,30,00020,910,30,0quadriceps tendon PA
0,07912,04,54,80,00315,06,81,2m.iliopsoas FE
0,01010,93,90,00,0806,53,60,0m.triceps brachii UL
0,2074,13,50,00,0757,22,31,2m.biceps brachii RA
0,3305,02,31,30,0065,90,00,0m.deltoideus CL
N=92-101 N=76-89 N=67-84 N=91-101 N=78-88 N=70-83
P( 2)OAMA YAP( 2)OAMA YA
RIGHT LEFT Males
0,00062,515,04,00,00056,114,87,4Achilles tendon CA
0,2931,60,00,01,60,00,0m.soleus TI
0,7131,73,11,20,2763,33,00,0qudriceps tendon TI0,00036,813,61,40,00032,115,03,9quadriceps tendon PA
0,0568,11,61,30,00013,10,00,0m.iliopsoas FE
0,0467,50,01,61,91,71,4m.triceps brachii UL
0,1064,91,60,05,00,00,0m.biceps brachii RA
0,00012,90,00,00,00011,50,00,0m.deltoideus CL
N=53-62 N=57-66 N=63-83 N=57-61 N=60-66 N=74-82
P( 2)OAMA YAP( 2)OAMA YA
RIGHT LEFT FemalesFrequency of EF (2+3%)
Males - LEFT Frequency of OL (1% - 2+3%)
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0,0
5,0
10,0
15,0
20,0
25,0
30,0
c o s
t o c
l a v . C
L
d e
l t o i d e u s C
L
p e c
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b i c e p s
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s o
l e u s
T I
Females - LEFT
YA
MA
OA
0,0
10,0
20,0
30,0
40,0
50,0
60,0
70,0
c o s
t o c
l a v .
C L
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l t o i d e u s
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l i s m .
H U
l a t . d
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H U
b i c e p s
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R A
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l e u s
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c o s
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l a v .
C L
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l a t . d
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H U
b i c e p s
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R A
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l e u s
T I
YA
MA
OA
PITTING (grade 1) EROSIONS (grade 2+3)
Frequency of OL (1% 2 3%)
Males
significant differences amongage classes
pitting (OL 1) increases withage
erosions (OL 2+3) decreaseswith age (except m. biceps brachii )
Females
no significant differencesamong age classes (except m.biceps brachii )
no age pattern
erosions more frequent in Mpitting more frequent in F
PITTING (grade 1) EROSIONS (grade 2+3)
R Humerusd
R Tibia( )
R Humerusf ( )
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EROSIONS PITTING
Males
erosions juvenile featurepitting elderly feature
Sardinia, ossuaryVCN t. 155 (Y)
m. soleus
Tf XXVII-2 (M?, Y)
L HumerusSS 296 M, 62 y.
m. pectoralis major
m. pectoralis major
m. latissimus dorsii / teres major
bone metabolism changes throughtime, bone response thus different?
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OCCUPATION
Males with known occupation
173 males with known occupation, performing 47 different jobs!
39% farmers, 5% masons
237313traders/employees
173565958MALES
49231511other
craftsmen
farmers
3410915
67163219
TotOAMAYA
Few significantdifferences
between jobs
Concluding remarks 1
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Entheses and enthesopathies as activity markers
age markers influenced by activity
instead of
activity markers influenced by age!
Increasing development of ROB and EF with age adaptive response ofthe bone to microtraumas from normal body movements accumulating over time.EF, OL more frequent at some entheses: maybe in relation to the anatomical structure of the enthesis
g
The increased surface area created at the tendon-bone junction may be an adaptive mechanism to ensure the integrity of the interface in response to increased mechanical loads.
Bony spur formation in the rat Achilles tendon is essentially an extension of normal bone development and is endochondral ossification through fibrocartilage rather than hyaline cartilage . (Benjamin et al., 2000 )
Concluding remarks 2
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But a hope remains 1. The study of homogeneous samples with respect
to the occupation gave interesting results (seeMilella et al. on porters and shoemakers -TOMORROW!!!)
2. The study of MSM and joint features inindividuals with altered patterns of locomotionhighlighted the influence of mechanical stress, inagreement with medical data (Belcastro and Mariotti,2000; Mariotti and Belcastro 2001)
Two Roman skeletons fromCasalecchio (Bologna, II-III AD)
3. Our results are referred to only 23 entheses,and maybe other entheses are more sensible tomechanical stress
4. We analised only the Sassari sample, but thereare many other known collections that can bestudied and that may give different results
Concluding remarks 3
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To obtain reliable results about past activities:1. Exclude individuals affected with diseases influencing the features
considered (e.g. DISH)
2. Exclude individuals with generalised high or low development of enthesesConsider only individuals presenting - clear bilateral asymmetry
- only some entheses developed
3. Compare groups of the same sex and age class (or at least with the sameage distribution), better if MA (or YA)
4. Consider all the possible activity markers (not only MSM)
5. Be very careful in the interpretation (taking into account possible sampling
problems, the age, and, obviously, the archaeological or historical record)
g
Scoring method:
Record ROB, EF and OL separately: they do not behave in the same wayin relation to age