1998- hawkey (ankilosis y discapacidad)

International Journal of OsteoarchaeologyInt. J. Osteoarchaeol. 8: 326340 (1998)

Disability, Compassion and the SkeletalRecord: Using Musculoskeletal StressMarkers (MSM) to Construct anOsteobiography from Early New MexicoDIANE E. HAWKEY*Department of Anthropology, Arizona State University, Tempe, AZ 85287-2402, USA

ABSTRACT Activity patterns seen in the skeletal remains of an adult male (burial 391) from Gran QuiviraPueblo, New Mexico, suggest his complete dependence upon others during the progression of adebilitating disease that began in childhood and lasted until his death in middle adulthood. Thecombination of clinical disease progression data and joint mobility estimates provide a pattern tohelp interpret the potential range of his movements. The pattern can then be examined in relationto results obtained from musculoskeletal stress marker (MSM) data. The MSM data for GranQuivira 391 contrasts sharply with the activity patterns commonly seen in MSM scores for otheradult males also dating to the Late Period occupation (AD 15501672) at the site. All three of theabove methods not only enable assessment of the extent of his impairment throughout life, butmay also provide information concerning the degree of disability within the community. Althoughcompassion cannot always be determined from the skeletal record alone, the severity of hiscondition suggests that he was wholly dependent on at least one other member of the groupover a long period of time. 1998 John Wiley & Sons, Ltd.

Key words: musculoskeletal stress markers; disability; Gran Quivira; juvenile chronic arthritis

Introduction

Ethnographic studies can provide clues aboutcommunity attitudes toward physical impair-ment. However, attempts to determine the de-gree of impairment (and resultant disability)from the skeletal evidence alone are problem-atic, and the assumption that the survival ofsuch an individual provides evidence of compas-sion has been challenged [1]. Activity patternsinterpreted from musculoskeletal stress markers(MSM) of an adult male (burial 391) from GranQuivira Pueblo, New Mexico, suggest completedependence on at least one individual during hislife. Palaeopathological analysis (Table 1) sug-gests that he suffered from a systemic form ofjuvenile chronic arthritis, a debilitating condi-tion that began in childhood and lasted intoadulthood until his death.

But before the degree of impairment can beassessed, it is first necessary to establish signsand timing of the disease, and then estimate if

Table 1. Osseous expressions typical and atypical of juvenilerheumatoid arthritis (JRA) as noted in the clinical literature[2,4,7,912] and present in Gran Quivira 391

Skeletal expressions consistent with JRA Growth disturbance of the long bones, resulting in

premature epiphyseal closure Antegonial notching of the mandible, deformity of

mandibular condyles Symmetrical involvement of more than four joints Bony ankylosis of major joint complexes, also seen in

small peripheral joints Pencil-in-cup appearance of the articular ends of the

hand phalanges Boutonniere deformity of the thumb Enlarged, osseous lesions at the joints A lack of involvement at the cartilaginous joints A minor degree of atlanto-occipital subluxation

Skeletal expression atypical of JRA Bony ankylosis of hips and thoracolumbar region Lack of extensive involvement of cervical vertebrae Tarsal joint involvement

* Correspondence to: Department of Anthropology, Arizona StateUniversity, Tempe, AZ 85287-2402, USA. Tel.: 1 6029655016; e-mail: [email protected]

CCC 1047482X:98:05032615$17.50 1998 John Wiley & Sons, Ltd.

Received 24 October 1997Revised 10 March 1998Accepted 24 May 1998

Disability, Compassion and Skeletal Record 327

his movements had been restricted during dif-ferent stages of his life. A predictive activitypattern can then be proposed and MSM datacan be used to test the pattern. Once the degreeof impairment is established, the extent of dis-ability for Gran Quivira 391 within his commu-nity can be compared with the typical range ofactivities observed in the MSM patterns ofother adult males of the same time period.

Juvenile chronic arthritis

The pattern of skeletal involvement in GranQuivira 391 indicates he suffered from juvenilechronic arthritis (JCA), a general term favouredby Resnick and Niwayama [2] that includesarthritic conditions of unknown etiology thatbegin in childhood. Histological analysis of thisspecimen [3] supports the early age onset of thecondition, which may include juvenile-onsetrheumatoid arthritis (JRA) in its systemic form(Stills disease), and juvenile-onset ankylosingspondylitis (JAS). Although the two conditionsare difficult to differentiate clinically [4], JRAmay either be a variant of JAS [5,6] or mayco-exist in individuals with JAS [7,8]. Severalalternative conditions were considered in myinitial examination of Gran Quivira 391, includ-ing Reiters syndrome, psoriatic arthritis, andother seronegative spondyloarthropathies. How-ever, the overall pattern is consistent with theconditions seen in the systemic form of JRA[2,4,7,912], particularly if Stills disease en-compasses both JRA and JAS.

Although bony ankylosis of the thoracic andlumbar regions and a lack of extensive involve-ment in the cervical vertebrae in Gran Quivira391 are indeed unusual in rheumatoid arthritis,it does suggest the possibility of a JRA co-oc-currence with ankylosing spondylitis. The ap-pearance of JAS is generally correlated with ahigh frequency of the HLA-B27 marker, particu-larly in males [2]. Although the genetic markeris typically found in low frequencies in individu-als with JRA [9], the HLA-B27 haplotype doessometimes occur in individuals with JRA, andmay identify children who are at risk of con-tracting JAS [13]. In Native Americans fromNew Mexico, presence of the B27 allele does

occur [14] with up to an estimated allele fre-quency of 0.21 in some modern groups [15].

Skeletal evidence for JRA obtained from thearchaeological record in the New World isscarce, consisting of a mid-adult female fromKodiak Island [16] and a young child from Peru[17]. A variety of problems may have hinderedrecognition of the condition, however, includ-ing a lack of detailed description of the shortbones of the hands and feet, crucial in assess-ment of most forms of rheumatoid arthritis. It isonly within the twentieth century that rheuma-toid arthritis has even been considered a sepa-rate entity from other forms of degenerativejoint diseases [13]. In fact, New World rheuma-toid arthritis may be a recent variant of ankylos-ing spondylitis, a condition whose antiquity isestablished in both the Old [6,12,13,18,19] andNew World [12,13,2022].

Materials and Methods

Burial 391 was recovered from Mound 7 at thepueblo site of Gran Quivira (Las Humanas),located in the Rio Grande region of centralNew Mexico. His death appears to have oc-curred during young-middle adulthood, an esti-mate based primarily on degree of dental wear,amount of secondary dentine, and the presenceof calculus deposits at the cementoenameljunction on all third molars. Although ectocra-nial suture closure had begun, no closure ofendocranial sutures had occurred. The pubicsymphyses could not be used to assess age atdeath due to pathology present in the innomi-nates. Four age categories were used to evaluatedisease progression: 1) childhood (up to age 16years), 2) juvenilesubadult (1620 years), 3)young adult (2130 years), and 4) middle adult(3140 years).

A complete understanding of disease processfrom skeletal remains alone is difficult to accom-plish, but a combination of skeletal indicators(i.e. progressive effect of the disease, joint mo-bility range, MSM data) may provide a possiblescenario for changes that occurred in the life-time of Gran Quivira 391. As summarized inTable 1, JRA (Stills disease) is most consistentwith the skeletal pathology observed in this

1998 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 8: 326340 (1998)

D.E. Hawkey328

individual. Stills disease exhibits very distinctstages in living individuals [2,4,7,912]: 1) thesynovial membrane of the joint first becomesinflamed. Movements are painful and the joint isoften involuntarily immobilized, contributing toosteoporosis in the affected region. 2) Forma-tion of pannus (a layer of granulation tissue)then occurs, followed by destruction of thearticular cartilage and subchondral bone. 3) Thepannus soon fills the joint space, and sizeablesoft tissue cyst-like formations often appear inthe weight-bearing regions of the body. Thesecysts can either contribute to joint destructionby having an erosive lytic effect on the cortexor can manifest itself as large, expanded osseouscysts. 4) The inflammation subsides, althoughfibrous adhesions and non-osseous ankylosis oc-curs, eventually causing subluxation and muscleflexion contracture. 5) The fibrous adhesionscan then ossify into bony ankylosis of the joint.

Given the disease pattern noted above inliving individuals, it is probable that GranQuivira 391 may have followed a similar pro-gression pattern. Thus, it is expected that theskeletal manifestations of the disease wouldhave occurred in the order that the clinicalliterature suggests: 1) osteoporosis, 2) osseouserosion of subchondral bone, 3) appearance oflytic lesions on cortical bone and:or presence ofosseous cysts, and 4) bony ankylosis of thejoints. By inference, the type and degree ofskeletal involvement can be used to clock thesequence of disease progression. For example, inGran Quivira 391, all joints in the hips werecompletely ankylosed at the time of death, al-though the knees were at an earlier stage (os-seous cyst formation); movement was impossibleat the hip joint, although there may have beenlimited mobility in the knees.

Next, a general estimate of joint mobility wasdetermined for each age category. Every jointcomplex (with the exception of absent skeletalelements from the sacrum, most right and lefttarsals:metatarsals:pedal phalanges) was visuallyinspected and scored, with a total possible scoreper joint based on degrees of movement possi-ble. For example, there are three degrees ofmovement present at the glenohumeral joint(flexion:extension, abduction:adduction, rota-tion) [23]. I assigned one point for each degree

of movement; if flexion alone was possible, thejoint complex was assigned a score of 0.5, but ifall motions were possible, a total score of 3.0was given. Estimation of mobility was based ona number of factors, including presence anddegree of ankylosis, osteophyte development,and ligamentous ossification. The values ob-tained allowed for quantification of mobilityloss at each stage of disease progression.

Data were then collected for presence (de-gree and type) of musculoskeletal stress markers,defined as any non-pathological marking thatoccurs at a muscle, ligamentous, or tendinousattachment site. I have based my scoring system[2426] on the earlier method of Angel andco-authors [27], who utilized a progressive se-ries of plus marks to indicate the relative degreeof muscle insertion hypertrophy observed onbone. While this was the first attempt to stan-dardize a scoring system, Angel et al. cautionedthat their system relies for its accuracy mainlyon the experience of the observer [27].

In an attempt to help lessen the need forextensive observer experience, and to enhancecomparability of intra- and inter-observer re-sults, I have utilized a series of photographs,accompanied by a written description, for threemain categories [2326]: robusticity, stress-in-duced lesion, and ossification. Within each ofthe categories are three grades (from absent0to strong3) representing consistent break-points at which the majority of observers agreein both inter- and intra-observer comparisontests [26,2835].

Two distinctions made within the robusticity(hypertrophy of attachment) category includemuscle-to-bone (Figure 1) and tendinous inser-tion (Figure 2) sites. Muscle-to-bone attach-ments require a slightly larger area ofattachment to prevent rupture when stressed,primarily due to lower tensile strength of musclewhen compared to tendon. The tendinous inser-tions are affected by layers of hyaline cartilagebetween the tendon and bone, preventing re-sorption or formation of new bone, althoughthe surrounding areas do reflect the stress ofmuscular pull. Stress-induced lesions have anirregular, lytic-like appearance (Figure 3) andmay be the result of continual microtrauma atthe insertion site [24], delaying the healing



Figure 1. Robusticity scores at the pectoralis major insertion site [2426]. Scores from left to right are, a) absent: no markingis seen. b) R1 faint: the cortex is only slightly rounded, and often not visible without viewing under strong light. The elevationis palpable, although no distinct crests or ridges have formed. c) R2moderate: the cortical surface is uneven, with amound-shaped elevation that is easily observable. No sharp ridges or crests have formed. d) R3strong: distinct, sharp crestsor ridges have formed.

process, and ultimately resulting in a necroticappearance of remaining bone. The ossificationcategory (Figure 4) is due to abrupt macro-trauma, creating a bony exostosis where tissueand:or ligaments ruptured and later ossified.

Analytical categories in this scoring systemare based on personal observations of more than1500 skeletons from broad temporal and culturalperiods throughout the southwestern UnitedStates, Canada, the Aleutian Islands, Africa, In-dia and Europe. This tripartite system of scoringMSM variation has been used for the past 10years, with some degree of modification[26,2835]. Categories are broadly defined toaccommodate the variety of factors involved inbone remodelling, including differing biome-chanical stress due to age and sex differences,individual variation in attachment, hormonal in-fluences, and type of muscle attachment.

Due to the range of variation in individualsize and expression of muscle markings, thecategories present ranked rather than intervaldata. Thus, an increase in numerical valuewithin a category represents an approximateincrease in degree of MSM expression and mus-

cle use. By utilizing the data in this manner,statistical comparisons can be made within andamong categories, and replicability of resultscan be addressed. All three categories arerecorded separately, although occasionally twocategories may be scored for the same attach-ment site. The strongest grade robusticity score(R3) and faintest stress lesion (S1) have oftenbeen found to occur at the same attachment sitewithin an individual, and may represent a con-tinuum between the two categories [24,25].

Results and interpretations ofmobility estimates

Childhood (less than 16 years old)

During this period, Gran Quivira 391 main-tained full mobility of all joints (Table 2), andthere is no skeletal evidence that he sufferedany unusual childhood illness prior to this stage.Healed porotic hyperostosis along the coronaland sagittal sutures was evident, although thiscondition is not uncommon among Gran


D.E. Hawkey330

Figure 2. Robusticity scores (tendinous attachment type) at the biceps brachii insertion site [2426]. Scores from left to right are,a) R1 faint: there is a slight indentation at the site of attachment, but no well-defined surrounding margin of bone. b)R2moderate: roughening of the attachment site occurs, most often with well-defined surrounding margin of bone. c)R3strong: deep indentation occurs with a clearly defined margin of bone. Usually the roughened area has developed crestsof bone.

Quivira children of the time period [36]. Thecharacteristic prodromal symptoms may havebegun, since the initial onset of JRA rarely occursafter age 16 years [37]. The majority of JRAcases in males begin in the systemic form [38],so early symptoms of high fever, malaise,anorexia, anemia, and morning stiffness of jointsmay have occurred by this time. While symp-toms are clinically known to subside after a6-month period [14], episodes of JRA have beenknown to last for a few weeks to months, or evenas long as years, often exacerbated during colderwinter months [39]. There are often periods ofsustained remission that may occur during thejuvenile period, only to intensify during adult-hood, causing the first instance of noticeabledeformity [40].

Juvenile subadult (1620 years old)

The age at which the next stage occurred isdifficult to determine, although the onset of thedisease probably began no later than 17 years ofage. In living individuals the epiphyses of the

long bones close prematurely, and this cessationof long bone growth in combination with greatlyatrophied bones, is known as rheumaticdwarfism [2,9,10,38]. The atrophy and greatlyshortened long bone lengths of Gran Quivira391 suggest a similar pattern in early epiphysealunion. The mandible also reflects this growthcessation, exhibiting a micrognathic appearancewith antegonial notching and obtuse angle to therami, expressions typically found in JRA [2]. Inaddition, the left temporomandibular joint(fossa and condyle) is malformed, with the lefttemporal fossa considerably smaller than theright side.

By this stage there was an estimated 17%mobility loss. Muscle flexion contraction and theresultant bony fusion of the hip (Figure 5), elbowand wrists (Figure 6) had occurred, precludingany further movements in these regions. Ankylo-sis of the hip joints in a flexion contracture mayhave been related to an attempt to minimizeintense pain; involuntary hip joint flexion isoften noted in children suffering from JRA,because this position provides some relief [41].



Figure 3. Stress-induced lesion scores at the pectoralis major insertion site [2426]. Scores from left to right are, a) S1 faint:a shallow furrow, a pitting (B1 mm in depth) into the cortex with a lytic-like appearance. b) S2moderate: pitting is deeper(\1 mm, but B3 mm in depth) and covers more surface area. It may vary in length, but never \5 mm. c) S3strong: pittingis marked, and \3 mm in depth, and \5 mm in length.

Gran Quivira 391 still maintained completemobility at both glenohumeral joints, the tem-poromandibular joint, and both knees and an-kles, with little significant effect to the vertebralcolumn. The third digit of each hand was com-pletely fused at the metacarpophalangeal (MCP)joint, with the proximal interphalangeal (PIP)joint ankylosed in a slight palmer contraction.All other MCP joints recovered during excava-tion indicated that limited flexion was possible,with the first digit of the right hand exhibitinga boutonniere [2] deformity (flexion at theMCP joint and hyperextension at the PIP joint).

Young adult (2130 years old)

A loss of mobility in the thoracolumbar regionappears to have occurred. By this time, GranQuivira 391 may have lost as much as 44% jointmobility with most movements significantly cur-tailed. Although it is uncertain when in adult-hood these problems occurred, these particularsymptoms usually appear in the earlier, ratherthan later course of the disease (B.M. Roth-schild, personal communication, 1997). He mayhave been affected by spinal scoliosis (elonga-

tion of cervical:thoracic spinous processes,asymmetrical development of ribs), at the be-ginning of adulthood; one instance in the clini-cal literature notes scoliosis occurred in an adultwith JRA [42]

Ossification of the T2T5 flavian ligamentsinto auxiliary pseudojoints made lateral move-ments more difficult. There is evidence of pit-ting on the T6T9 apophyseal facets, alongwith general osteoporosity of all elements in thethoracolumbar region. Bony ankylosis of apo-physeal facets occur from the inferior T9 tosuperior L3. Extensive osteoarthritis, along withossification of the flavian ligaments into a smallpseudojoint at the L3L4 articulation, wouldhave enabled some limited flexion:extension.From L1 to L3 there is ventral collapse of theintervertebral disc space, and both L2 and L3exhibit initial ankylosis of the ventral vertebralbodies. Complete ankylosis of apophyseal facetsand vertebral bodies of L4 (inferior) to S1(superior) was noted, but without the remainderof the sacrum below S1 (not recovered duringexcavation), it is impossible to know if all sacralelements were ankylosed. Loss of lower backmovement would have made sitting upright im-possible without assistance.


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Figure 4. Ossification scores at various attachments sites on the humerus [2426]. Scores from left to right are, a) Os1 faint:a slight exostosis occurs, usually rounded in appearance, and extends B2 mm from the cortical surface. b) Os2moderate:there is a distinct exostosis, varied in shape, that extends \2 mm, but B5 mm from the surface of the cortex. Two examplesare depicted of c) Os3strong: The exostosis extends \5 mm from the surface of the bone, or covers an extensive amountof cortical surface.

Middle adult (3140 years old)

Joint mobility may have decreased to nearly50%, and was limited to the head, neck, shoul-ders and flexion of the hand phalanges. Inaddition, large, expansive osseous lesions hadnow affected both knees and ankles. The kneeswere locked into a flexed position, and the leftpatella was osteoporotic and fused to this bonymass. Except for the five right metatarsals(which also exhibited similar osteoporosis andosseous lesions) the remainder of the feet wereso poorly preserved that they disintegrated dur-ing excavation. A portion of the right fifthmetatarsal was ankylosed to the cuboid.

Enlarged, cyst-like lesions billow out at boththe knee and ankle joints. Femoral mid-shaftdiameters are extremely small (1212 mm) butballoon out to a maximum of 72 mm at thedistal ends (Figure 7). The medullary cavity atfemoral mid-shaft (measured from a thin sec-tion) is almost non-existent with only a 2 mmmaximum diameter. Similar observations weremade for the lower leg, where the left fibula iseven more atrophied (11 mm mid-shaft di-

ameter) than the right (47 mm diameter).The glenohumeral joints began to show os-teoarthritic pitting on the articular surface ofboth humeral heads and the correspondingglenoid fossae, probably due to excessive com-pensatory use placed on this joint.

Several other conditions were present in GranQuivira 391 at the time of death, but it isimpossible to estimate the age at which theyfirst appeared. The cervical region displays aminor degree of atlanto-occipital subluxation,slight elongation of the C2 odontoid process,and slight ossification of the C1 anterior liga-ment. Both orbits and malars are asymmetricaland disproportionate in appearance (Figure 8),with the right side noticeably larger than theleft. Evidence of trauma occurs on the left sideof his facea large, remodelled gash inferior tothe left superciliary ridge, along with healedfracture of the nasal bones.

There are no skeletal markers that indicatecause of death. Clinically documented causes[9,14,37] suggest a number of possibilities, in-cluding rheumatoid lung disease, spinal cordcompression due to atlanto-occipital subluxa-



Table 2. Joint mobility estimates for Gran Quivira 391, including total scores possible for each region, andscores obtained for each stage, as determined by disease progression data for right (R) and left (L) sides.A score of 0 indicates a lack of mobility

Stage I Stage II Stage III Stage IVRegion (total score possible)

3 3Cranial (3) 33R7:L7 R6:L6R7:L7R7:L7Shoulder (14)

R0:L0R0:L0Elbow (4) R2:L2 R0:L0R0:L0 R0:L0Wrist (4) R2:L2 R0:L0

R10.5:L8R10.5:L8 R10.5:L8R19:LHand, right (19):left (11)R0:L0 R0:L0Hip (6) R3:L3 R0:L0

R1:L1 R0:L0Knee (2) R1:L1 R1:L1R1:L1 R1:L1Ankle (2) R1:L1 R0:L0R R11 R10R11Foot, right (11)18 18Vertebra, cervical (18) 181839 15Vertebrae, thoracic (39) 39 15

1.51.518 18Vertebrae, lumbar (18)

151.0 125.5 85.0 78.0Total points possible (151)56% 52%Mobility possible 100% 83%

tion, or septicaemia from a localized infection atone or more of the inflamed joints. Similarly,renal amyloidosis and thromboembolism shouldalso be considered, although they also do notaffect bone.

Results and interpretations of MSMdata

The disease progression pattern described,along with joint mobility estimates, suggest thatduring adolescence Gran Quivira 391 had lostall mobility in the hip, elbows and wrists, butkept a minor amount of mobility in the lumbarvertebrae (8%), and some mobility in the tho-racic region (38%). The hands were not yetaffected, with 73% mobility in the left (scoredfor 19 joint regions), and 55% in the right(scored for 11 joint regions). By young adult-hood he had lost all mobility in the kneesand ankles, but the head and neck (including allthe cervical vertebrae) maintained complete mo-bility, along with 86% mobility in both shoul-ders.

Although the exact rate of bone remodellingis unknown, it is not unreasonable to assumethat MSM scores would indicate stress placed

on muscles (with the highest scores) sometimeprior to middle adulthood. With this assump-tion in mind, the MSM data lend support tothe activity pattern predicted by the diseaseprogression and joint mobility estimates (Table3).

A considerable amount of movement was pos-sible in the head, shoulder, and arm regions,with the highest scores (R3 and above, andincluding Os1 and 2 categories) in the entirebody for the insertion sites of masseter, pterygoideusand rectus capitus muscles, sternocleidomastoid, del-toideus, and the conoid and trapezoid ligaments.Muscles utilized in flexion:extension and rota-tion of the head appear to have been stronglystressed, with the muscles on the right sideusually more pronounced than the left. StrongMSM for the platysma myoides and levator labiisuperioris (two of the rather poetically namedmuscles of melancholy) suggest his face wasdrawn downwards, perhaps related to the in-juries suffered in the incident of facial trauma.

Unusually high scores for both the conoidand trapezoid ligamentous attachments suggesta strong degree of stress was placed on theshoulders, especially in actions limiting the rota-tion of the scapulae. In general, the right shoul-der and arm muscles were more strongly


D.E. Hawkey334

Figure 5. Medial aspect of the right innominate and femur, with the femur ankylosed at almost 90 to the iliac blade.

utilized than the left. High scores for musclesrecruited in arm adduction, medial rotation ofthe arm, and flexion of the arm at the shoulderare common, although MSM evidence for armabduction, lateral rotation and extension of thearm at the shoulder are also apparent to aslightly lesser degree.

Similarly, supination:pronation, especially ofthe right forearm and hand (e.g. supinator, prona-tor teres, pronator quadratus) are also suggested bystrong MSM scores for these muscles. Flexion ofthe hand at the wrist ( flexor carpi ulnaris, pronatorteres) is also seen in higher MSM scores for theright side, with evidence for the flexor carpiulnaris assisting in wrist adduction.

The MSM results for the lower extremitytend to lack strong expressions, suggesting thatthe muscles of the hip and leg were not signifi-cantly utilized in the later stages of his life. Theonly markings with strong scores are those mus-cles which aid in flexion of the thigh at hip(vastus muscles, psoas-iliacus) and flexion:exten-sion of the trunk at hip (gluteus maximus, psoas-ili-acus) with some evidence for abduction of theleg at the hip joint (gluteus medius). These scoresare likely related to the flexion contractureactions.

Discussion

By utilizing a combination of the three skeletalindicators (disease progression, joint mobility,MSM), a hypothetical scenario to explain thedegree of disability for this individual may beoffered (Figure 9). During adolescence, GranQuivira 391 was not completely helpless, al-though flexion contracture and the resultantbony fusion of the hips, elbows and wrists hadoccurred, making movements in these regionsimpossible. The knees could still be bent, withthe feet placed flat on the ground. Bony callosi-ties occurred on the ischia, lumbar spinous pro-cesses, and right elbow, consistent with ahabitual posture of resting while in a proneposition on his back. Although walking wasimpossible, the degree of joint mobility andstrong MSM scores for the shoulder regionsuggest movement was possible by inching for-ward or backward in the supine position, usinghis right elbow:left arm and his feet to pushhimself along.

During the latter stages of his life, movementwas limited solely to the head, neck and shoul-ders, along with some flexion capability in thephalanges of the hand. Inching back-and-forth



while on his back could still be accomplished,but would have been increasingly difficult,involving slowly dragging the body along bypushing against the ground using only theright elbow, aided weakly by the left arm. Bythis time, the large osseous cysts in the legshad begun to ankylose. Neither of the legs hadany significant MSM other than those related(in all probability) to the flexion contractureaction, with the lower extremities unlikely tohave been utilized during the latter stages of hislife.

Conclusions

Data obtained from the clinical literature, jointmobility measurements, and MSM results canhelp assess the degree of Gran Quivira 391simpairment and disability. Can we take thesedata a step further and ask if compassion wasdisplayed towards him? Because he maintainedsome mobility in his head, neck, and shouldersthroughout his life, he was probably capable ofbringing food to his mouth. Given the severityof his condition he would have required some-one to supply him with food. Similarities inamount of occlusal wear and lack of cariesbetween Gran Quivira 391 and inhabitants ofthe pueblo during this time period, suggest thathe shared a similar diet with other residents.However, the strong muscle mastication scoresobserved in Gran Quivira 391 may indicate heconsistently consumed food that was difficult tochew. It is also possible that the shortened ramiand condylar deformity of his mandible mayhave placed unusual stress on the masticationmuscles, thus creating a pattern not normallyseen in other adults from Gran Quivira.

It is possible that his healed facial trauma wasdue to interpersonal violence; an alternate ex-planation may involve a fall during the earlystages of the disease, when walking was stillpossible, although difficult. Some form of treat-ment may have been implemented to alleviatewalking difficulties. Cushing observed a condi-tion among the early Zuni known as the warps[43] (kyphosis of the spine). The common curewas to strap an individual on a straight, hardboard, night and day. If Gran Quivira 391svertebral disorders had been treated in a similarmanner, the result would have been disastrous,because joint immobility would rapidly advancethe ankylosis process [41], and may help explainthe severely ankylosed condition of his spineand hips.

His disability within the framework of societyis more difficult to assess, although comparisonsof the MSM data [24] with other adult males(n32) from Late Period at Gran Quivira pointout several inconsistencies. Muscle use by themajority of adult males suggests considerablestress on the extensors of the arm and forearm

Figure 6. Right arm, forearm, wrist and hand, depicting anky-losis at the elbow, wrists, and aspects of the hand. Theshoulder joint is unaffected.


D.E. Hawkey336

Figure 7. Medial aspect of the right knee joint, exhibiting the large osseous cysts and greatly atrophied shafts of the femur, tibiaand fibula.

Figure 8. Frontal view of the cranium, exhibiting healed nasalfracture, remodelled (healed) gash on the left side near glabella,and asymmetrical appearance of the orbits and malars.

(e.g. triceps, anconeus, subscapularis). The pattern inGran Quivira 391, however, indicates a strongeremphasis on muscle actions consistent withmovements of the scapula (especially scoresfrom serratus anterior and pectoralis minor), and thepronators of the forearm (pronator quadratus,pronator teres).

Although Gran Quivira 391 may not havebeen able to perform activities commonly doneby others in his cohort, there is no archaeologi-cal evidence to suggest he was treated differ-ently. No other Gran Quivira skeletal remains(n361) had osseous evidence of an impair-ment of this magnitude. Although Gran Quivira391 was buried in a subfloor context, all otheraspects of the burial (body position, orientation,grave goods) were consistent with other adultburials at the pueblo. Because subfloor burials atGran Quivira were commonly reserved for chil-dren [44], the treatment after death suggests acertain amount of care had been given to thisman, quite probably by his family.

So, while the identity of, and the rationalefor, his care-giver(s) remain speculative at best,the condition of impairment observed in GranQuivira 391 indicates he was dependent on



Table 3. MSM data results for Gran Quivira 391; robusticity scores indicated are for all muscles with scores]grade 2. Muscle attachments listed below were scored at grade 2 or higher. Scores are indicated forrobusticity (R), and ossification (Os) categories. There were no stress-induced lesions (S) observed in thisindividual

Muscle name Origin score Insertion score

Right Left Right Left

Head and neck regionRB2.0 RB2.0 R3.5 R3.0Complexus

RB2.0RB2.0R2.5R2.5DigastricusR2.5 R3.0Levator labii superioris R2.0 R3.0R3.0 R3.0Masseter R3.5 R3.5b

RB2.0 R2.5Platysma myoides RB2.0 RB2.0RB2.0 R2.0 R3.0RB2.0Pterygoideus lateralisRB2.0 R3.0Pterygoideus medialis RB2.0 R3.0

R2.0R3.5:Os1RB2.0RB2.0Rectus capitis anteriorR3.5:Os1 R2.0Rectus capitus lateralis RB2.0 RB2.0R3.0 R2.0Rectus capitis posterior major RB2.0 RB2.0

RB2.0 R3.5:Os1Rectus capitus posterior minor RB2.0 R3.0R3.5b:Os2 R3.0R3.0R3.5:Os1Sternocleidomastoid

RB2.0 RB2.0 R2.0 RB2.0TemporalisRB2.0 RB2.0 R2.5 R2.5Trachelomastoid

Upper extremityaaBiceps brachii R3.5 a

R3.5 R3.5bDeltoideus RB2.0 RB2.0RB2.0 aFlexor carpi ulnaris R3.5 aa R2.0R2.0aLatissimus dorsi

RB2.0 R3.0 R3.5 R2.0Pectoralis majorR2.0R3.0RB2.0RB2.0Pectoralis minor

R3.0 RB2.0Pronator quadratus RB2.0 R3.0a R2.5Pronator teres a RB2.0

RB2.0R2.5RB2.0RB2.0Serratus anteriorRB2.0 RB2.0Subscapularis R2.0 RB2.0

a R2.0Supinator a RB2.0R2.0RB2.0 R2.0RB2.0Teres major

R2.0 RB2.0 RB2.0 RB2.0Teres minora aTriceps brachii R2.5 RB2.0

Lower extremityR3.5RB2.0 R2.0RB2.0Gluteus maximusR3.0 R2.0Gluteus medius RB2.0 RB2.0

aaR2.5R2.0Iliocostalis lumborumR3.0 R3.5Psoas-iliacus RB2.0 RB2.0RB2.0 RB2.0Semimembranosus R2.0 R3.0

R3.0 RB2.0Semitendinosus R2.0 RB2.0R2.0 RB2.0RB2.0R2.0Transversus abdominisa R3.0Vastus muscles a R3.5

ScoreLigament name

Right Left

Upper extremityRB2.0R2.0Conoid ligament (clavicle)R3.0R3.0Conoid ligament (scapula)R3.5:Os2.0R3.5:Os2.0Trapezoid ligament (scapula)

a Missing data.b Slightly higher scores for one side within the same category and grade.


D.E. Hawkey338

Figure 9. Proposed types of movement possible at juvenilesubadult and early adulthood stages, based on joint mobilityestimates and MSM data. (Artwork by Karen S. Taylor.)

other people over a protracted period of time.A combination of MSM indicators, joint mo-bility estimates, and clinical disease progres-sion data suggest that although severelyimpaired, Gran Quivira 391 was well-caredfor, permitting him to survive to middle age.

Acknowledgements

I wish to thank the National Park Service(Tucson, AZ) for permission to examine GranQuivira 391, and to Christy G. Turner II (Ari-zona State University), Bruce M. Rothschild(Arthritis Center of Northeast Ohio andNorthwest Ohio University), and Andrea L.

Buck (Arizona State University) for their manyinformative and helpful comments. In addition,many thanks to Karen S. Taylor, for the art-work in Figure 9.

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1998- hawkey (ankilosis y discapacidad)

Documents

skeletal evidence

degree of disability

degree of impairment

cartilaginous joints

skeletal remains

skeletal record

msm scores

gran quivirapueblo