Beyond the Adam’s Test: A Scoping Review of Innovations and Implementation Gaps in School-Based Screening for Adolescent Idiopathic Scoliosis

Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional spinal deformity of unknown etiology, defined by a Cobb angle ≥10° with vertebral rotation. It affects 1%–3% of adolescents globally, with higher prevalence among females and during periods of rapid growth. Although most mild curves remain stable, 10%–30% progress to severe deformity (Cobb angle >45°), often requiring surgical intervention¹. High-quality randomized controlled trials have demonstrated that initiating customized bracing during the 20°–40° Cobb angle window can reduce the risk of progression to surgical thresholds by up to 72% (RR 0.28)², underscoring the clinical value of early detection. School-based screening has long been implemented to enable early identification, primarily relying on the Adam’s Forward Bend Test (AFBT) followed by confirmatory X-ray imaging. However, this approach faces persistent challenges, including high false-positive referral rates, unnecessary ionizing radiation exposure, psychological burden on adolescents and families, and ongoing debates about cost-effectiveness. Notably, the U.S. Preventive Services Task Force (USPSTF) maintained an “I statement” (insufficient evidence) in its 2018 recommendation³, while countries such as China and Japan continue to integrate school screening into national public health programs—highlighting significant global divergence in practice. Recent advances in digital health offer promising alternatives: non-radiographic 3D surface topography (e.g., Formetric), smartphone-based AI-driven trunk analysis, and wearable inertial sensors may enhance screening accuracy while reducing burden. Yet these technologies vary widely in maturity, and their diagnostic performance, contextual applicability, and—critically—their implementation barriers (e.g., cost, training needs, data privacy, equity) remain fragmented across the literature. Given the heterogeneity and fragmentation of evidence in AIS school screening, a scoping review is urgently needed to map the current landscape and answer: What innovations exist? Where and how are they used? And why do implementation gaps persist?