Joint conditions in post-Medieval England: A comparative assessment of modern risk factors and historic lifestyles Ian M McAfee Department of Archaeology University of Sheffield Thesis completed for the degree of Doctor of Philosophy Submitted 19 March 2021 Abstract Pathological conditions of the joints are commonplace and incurable, affecting millions of living individuals and yet, surprisingly, there is a great deal that is still unknown about them, including the role and interactions of a variety of risk factors which underpin their development. Much can be learned about joint conditions in the past by marrying clinical and palaeopathological research and by examining patterns of prevalence for joint conditions amongst the living and the trends of the past, the risk factors can be better understood. This thesis aims to utilize palaeopathological evidence of specific joint conditions from past populations in an effort to critically evaluate and analyze the potential risk factors as researched in the clinical literature. This body of research assessed the joint conditions osteoarthritis, ankylosing spondylitis, sacroiliitis and degenerative disc disease in a sample of skeletal remains from sites across England dating to the 18th-19th centuries. Mature individuals, both male and female, (18+ years) were included. This allowed for the determination and insight into how the lifestyles of each site category affect the development of the joint conditions. A series of palaeopathological assessments were undertaken to generate a novel dataset that provided skeletal proxies for clinically identified risk factors of the joint diseases to determine whether any relationships/associations existed between the risk factors and joint conditions. Osteological assessments were conducted to create demographic profiles using the pertinent variables (age at death and biological sex), pathologies and the risk factors. These risk factors consisted of body mass (via skeletal height/weight estimation) and activity (via non-imaging cross-sectional geography and entheseal changes), which consisted of five variables, four of which were produced using a method of non-imaging cross-sectional geometry, with the fifth being the scoring of pertinent entheses. The prevalence rates of the joint conditions fell within the upper ranges of similar sites of post-medieval England and followed sex and age trends also seen in clinical research. These trends showed that the rates increased with age, however statistical testing did not display significance. Body mass and activity did not correspond with joint conditions in the archaeological sample in the same fashion reported in the clinical trials, resulting in a discussion that raised questions about the (1) accuracy and efficacy of currently available osteological methods used to create proxies for these variables from skeletal data, (2) the extent ii | McAfee IM: Joint Conditions in Post- Medieval England to which clinical and osteological methods of detecting joint condition offer comparable data and (3) the level which would cause changes to joint function cause a joint condition. However, the body mass of the samples used within this thesis may simply have been too low to have caused sufficient impairment/degradation to the joint, explaining the lack of correlation/association found compared to clinical studies. The variables used as proxies for activity levels did display a significance association with the joint conditions when tested individually. The final binomial logistical regressions found that only a small number of these activity variables were significant factors in the prediction of each joint condition, when all the variables were used in the test. Ankylosing spondylitis was not found to be present in any of the samples used and sacroiliitis was present in only a small percentage of samples and so were unable to be further tested. Further tests on a larger sample size to test the validity of the results found within this thesis, such as the body mass and activity findings, will need to be conducted. This will help to check the validity of the current data as well as to expand it further so new assumptions/conclusions can be made. The joint conditions conformed to the clinical trends concerning age and sex but differed concerning BMI and activity, offering insights into further avenues to explore. For the spondyloarthropathies, a greater sample size would help to accurately study ankylosing spondylitis and sacroiliitis by increasing the level at which inferential analyses can be made. This research, while concluded in its present form, provides a list of future directions to continue to explore the questions and limitations that have arisen throughout. iii | McAfee IM: Joint Conditions in Post- Medieval England Acknowledgements First and foremost, I would like to thank my family, which has continued to support me in many ways throughout my life. They encouraged me to follow my passions and continue with my studies, even though I am sure they would have been far happier knowing I was safe and secure in a job and able to provide for myself, rather than ever continuing to be a mature student. I would like to thank supervising team. Dr Elizabeth Craig-Atkins, I gave you a hard time and I know your name became a curse on more than one occasion, but I am glad to have had you one my side. Your constant support, encouragement and knowledge over the last 4 years has meant a lot to me. Dr Charlotte Henderson, your vast wealth of knowledge and insights concerning entheseal changes and spondyloarthropathies has been invaluable. Dr Kevin Kuykendall, your help with the statistical side has been enormous and I have learned much from what you suggested. My supervisors were my own personal A-Team, and for that, I am grateful. I would like to thank the universities and institutions that allowed me access to the skeletal samples used within this thesis. I was invited to these locations and treated, not like a stranger, but as a friend or member of the institutional family, making the travel and research easier to complete. For this, I will be forever grateful. I would like to thank Thomas Wood and Dr Sarah Reaney-Wood, mainly because you thought I would not add your names here. You both put up with me, helped me to decompress, and helped me through this difficult process. Sarah you helped me to find my way through my stats section and without that, I could never have finished this thesis. You both have become my family. To all the remaining family and friends, I have met along the way that made this difficult journey even the slightest bit easier, thank you. Thank you all, for your contribution to my work, large and small. Without you, I could not have done any of this. iv | McAfee IM: Joint Conditions in Post- Medieval England For my Aunt Peggy, who encouraged me to never stop learning v | McAfee IM: Joint Conditions in Post- Medieval England Ethical Considerations The author of this thesis acknowledges that the skeletal remains are those of once living human individuals and consideration for their care and handling was thoroughly considered before the research began. Throughout this research, the remains were treated with care and respect, following all personal and professional ethical guidelines of the researcher and the curating institutions (McGowan GS and LaRoche CJ, 1996; APABE, 2017; BABAO, 2019). In no way did this researcher use the skeletal remains for any purpose other than the scientific research stated in the following aims and objectives. vi | McAfee IM: Joint Conditions in Post- Medieval England Contents Abstract ...................................................................................................................................... ii Acknowledgements ................................................................................................................... iv Ethical Considerations .............................................................................................................. vi List of Figures .......................................................................................................................... xii List of Tables ......................................................................................................................... xxv Key Abbreviations .............................................................................................................. xxxvi Chapter 1 Introduction ............................................................................................................... 1 1.1 Thesis Structure ................................................................................................................ 1 1.1.1 Chapter 2 Aims and Objectives ................................................................................. 2 1.1.2 Chapter 3 Joint Conditions ........................................................................................ 2 1.1.3 Chapter 4 Sample Selection ....................................................................................... 2 1.1.4 Chapter 5 Methodology ............................................................................................. 2 1.1.5 Chapter 6 Results ....................................................................................................... 3 1.1.6 Chapter 7 Discussion ................................................................................................. 3 1.1.7 Chapter 8 Conclusion ...............................................................................................