Current Status of Scoliosis Screening Findings and Associations With Physical Activity and Health Behaviors Among Chinese Children and Adolescents: A Cross-Sectional Survey in Shanghai, Xinjiang, and Fujian

Technical Summary: Current Status of Scoliosis Screening Findings and Associations With Physical Activity and Health Behaviors Among Chinese Children and Adolescents

Problem Statement
Adolescent idiopathic scoliosis (AIS) is a prevalent three-dimensional spinal abnormality affecting approximately 1–3% of children aged 10–16 globally. While radiography (Cobb angle ≥10°) is the clinical gold standard, it is unsuitable for universal, large-scale school-based screening due to radiation exposure and cost. Consequently, non-invasive methods such as the Adam's forward bend test and Angle of Trunk Rotation (ATR) measurement are standard for initial risk identification. However, existing research has predominantly focused on traditional demographic and morphological risk factors (e.g., sex, age, BMI, family history), leaving a gap in understanding how daily lifestyle, physical activity patterns, and health behaviors influence abnormal spinal screening findings. Furthermore, regional variations in learning environments, sports participation, and health behaviors across China remain underexplored in the context of scoliosis risk.

Methodology
This study employed a cross-sectional survey design involving 9,464 students in grades 4–12 from three distinct regions in China: Shanghai, Xinjiang, and Fujian. Data collection occurred between September 2024 and August 2025.

• Screening Protocol: Scoliosis screening followed national standards and international procedures, utilizing a general physical examination, the Adam's forward bend test, and ATR measurement via a scoliometer.
  • Primary Outcome: ATR ≥7° was defined as the primary criterion for suspected positive screening.
  • Sensitivity Analyses: ATR ≥5° and ATR ≥10° were used as alternative thresholds to assess robustness.
  • Exclusion: Students with prior spinal surgery, brace treatment, or physical conditions preventing cooperation were excluded. Radiographic confirmation was not performed; thus, results reflect screening positivity rather than clinically confirmed prevalence.
• Data Collection:
  • Demographics & Morphology: Age, sex, height, weight, BMI, body fat percentage, and grip strength were measured.
  • Behavioral Assessment: A validated "Behavioral Risk Questionnaire for Spinal Health" (10 dimensions, 30 items) assessed sedentary behavior, unilateral force-dominant exercise, schoolbag burden, physical activity levels, outdoor activity, dairy intake, screen use, sleep, posture, and desk-chair matching.
  • Physical Activity: General activity levels were assessed using the International Physical Activity Questionnaire-Short Form (IPAQ-SF), calculating MET-min/week and sedentary time.
• Statistical Analysis: Multivariable binary logistic regression was used to identify factors associated with ATR ≥7° positivity. Models were adjusted for region, sex, grade, BMI, and family history. Sensitivity analyses were conducted across different ATR thresholds.

Key Results

• Screening Positivity Rates:
  • ATR ≥5°: 7.3%
  • ATR ≥7° (Primary Outcome): 3.0%
  • ATR ≥10°: 0.7%
  • Regional differences in detection rates were not statistically significant for the primary threshold.
• Demographic and Morphological Associations:
  • Sex: Females had significantly higher odds of screening positive compared to males (OR = 1.778, 95% CI: 1.389–2.275).
  • Grade Level: Higher grade levels were associated with increased risk (OR = 1.210 per grade).
  • BMI: Lower BMI was significantly associated with higher risk (OR = 0.866 per unit increase). Underweight students showed the highest positivity rate (10.7%).
  • Family History: A family history of scoliosis was the strongest predictor (OR = 4.703, 95% CI: 3.466–6.382).
• Behavioral and Lifestyle Associations:
  • Sedentary Behavior: Higher scores for sedentary behavior were associated with increased risk (OR = 1.105).
  • Physical Activity: Insufficient physical activity (OR = 1.082) and unilateral force-dominant exercise (OR = 1.096) were significant risk factors.
  • Sleep: Sleep insufficiency was associated with increased risk (OR = 1.098).
  • Non-Significant Factors: Schoolbag burden, poor reading/writing posture, and desk-chair matching did not show statistically significant associations in the multivariable models. Electronic screen use was significant only in the ATR ≥5° model, not at higher thresholds.
• Sensitivity Analysis: The associations for sex, grade, BMI, and family history remained stable across all ATR thresholds (≥5°, ≥7°, ≥10°). Behavioral factors showed varying significance depending on the threshold, with sleep insufficiency remaining a consistent risk factor across all models.

Key Contributions

1. Behavioral Risk Identification: This study expands the scope of scoliosis research beyond traditional morphological factors by quantifying the association between specific health behaviors (sedentary time, sleep, unilateral exercise) and abnormal spinal screening findings.
2. Regional Diversity: By sampling from Shanghai (coastal, high economic development), Xinjiang (inland, high altitude), and Fujian (coastal), the study provides a broader geographical perspective on scoliosis risk factors in China, revealing that behavioral risks persist across diverse environments.
3. Threshold Robustness: The use of sensitivity analyses across three ATR thresholds demonstrates that while behavioral factors may vary in significance based on the strictness of the screening criterion, demographic and family history factors are robust predictors regardless of the threshold.
4. Screening Positivity vs. Prevalence: The study clarifies that the reported 3.0% rate represents ATR-based screening positivity (suspected risk), distinguishing it from radiographically confirmed prevalence, which is typically lower.

Significance and Claims
The authors claim that abnormal spinal screening results in children and adolescents are not solely determined by growth, development, and genetics but are significantly influenced by daily lifestyle and physical activity behaviors.

• Targeted Screening: The findings support prioritizing school-based screening for specific high-risk groups: girls, students in higher grades, those with lower BMI, and those with a family history of scoliosis.
• Behavioral Interventions: The study suggests that behavioral interventions aimed at reducing sedentary behavior, improving sleep quality, promoting balanced physical activity, and avoiding unilateral force-dominant exercises may support spinal health.
• Management Shift: The authors propose a shift in school spinal health management from simple abnormality identification toward stratified management that integrates behavioral risk identification with physical education and lifestyle interventions.

Limitations
The authors acknowledge several limitations:

• Cross-Sectional Design: Causal relationships between behaviors and scoliosis screening results cannot be inferred.
• Lack of Radiographic Data: Without Cobb angle confirmation, the study reports screening positivity rather than clinical prevalence.
• Self-Report Bias: Behavioral data relied on student self-reporting, which may introduce recall bias.
• Sample Representativeness: Participants were recruited from selected schools in three regions, limiting the generalizability of findings to the entire Chinese population.
• Missing Variables: The study did not include pubertal stage, bone age, or objectively monitored physical activity.

Conclusion
The study concludes that ATR-based screening positivity is 3.0% among the surveyed population. It identifies a clear profile of risk involving female sex, higher grade level, lower BMI, family history, and specific negative health behaviors. The authors advocate for integrating these behavioral insights into school-based screening protocols to facilitate earlier identification and targeted, non-invasive interventions.