Results in this study showed that poor posture, spinal musculoskeletal dysfunctions and scoliosis were common in college students, which could be considered as three steps of spinal health problems among them. More specifically, poor posture in college students included external auditory meatus and acromioclavicular joint not in the same gravitational line, forward-head, uneven shoulders, head side bending off midline, round shoulders, protruding abdomen, etc. Spinal musculoskeletal dysfunctions mainly involved abnormalities of multi-segment spine flexion, cervical rotation and multi-segment spine extension. Among them, incidence of scoliosis was 10.78% measured by Adam's Test. Khosrovi et al. reported a higher prevalence of 17.9%  among same age group in Iran. Thus, spinal health of college students is a serious problem.
By Spearman correlation analysis, we found that key postural factors related to spinal musculoskeletal dysfunction included uneven shoulders, forward-head, position of thorax and pelvis rotated, changes of thoracic kyphosis and head rotation off midline (Table 3). It’s reported that musculoskeletal pain among undergraduate students is related to overweight, not having time for leisure, six or more daily hours of mobile phone use . While prolonged sitting and reduced flexibility were probably related to incidence of forward head, thoracic kyphosis, and pronated foot . Casas et al. found that neck and back pain of college students is associated with sitting posture with rounded back, feet supported on another chair and crossed legs . Thus, correcting cervical and thoracic postural abnormalities when long hours sitting is the key point for prevention of musculoskeletal dysfunctions.
Postural factors related to scoliosis were spinous processes line deviating from midline, winged scapula and head rotation off midline (Table 4). It’s known that trunk balance is maintained by mutual interaction of varieties of factors including visual information, lower limb kinematics, muscle strength of the trunk and limbs and so on . After a long time for deviation of spinous processes line, head and cervical spine play pivotal roles in influencing global subjacent spinal alignment and pelvic tilt, as compensatory changes occur to maintain horizontal gaze . And head rotation off midline maybe a way of visual compensation for trunk unbalance. Besides, Purnama et al. found winging scapula was identified in all athlete’s table tennis and tennis with scoliosis because of muscle imbalance in the kinetic link of the upper body . It’s also reported that main compensatory mechanisms of scoliosis patients adopt to maintain an upright posture include decreased sacral slope, increased pelvic tilt, decreased thoracic kyphosis . Once it does decompensate, three-dimensional deformation of spine will be induced or severe. Therefore, early inspection on the spinous processes line, winged scapula and head rotation, should be considered as routine interventions to effectively identify the progress of scoliosis in college students.
By binomial logistic regression analysis, external auditory meatus and acromioclavicular joint not in the same gravitational line was shown as one of the high risk factors for scoliosis in this study (Table 5). External auditory meatus and acromioclavicular joint not in the same gravitational line usually means rotation or forward displacement of the head on the cervical spine . In this study, 14% of college students appeared head rotation, and 45% had forward-head posture. The latter can be considered as the main cause of external auditory meatus and acromioclavicular joint not in the same vertical line. Forward-head posture is characterized by hyperextension of the upper cervical spine and flexion of the lower cervical spine, which is associated with shortening of the upper trapezius, posterior cervical extensor muscles, sternocleidomastoid, and levator scapulae muscles . With the increase of compressive forces caused by forward-head on the cervical apophyseal joints and posterior part of the vertebra and changes in connective tissue length and strength, cervical lordosis and thoracic kyphosis values will be significantly affected . Maybe this is the hidden mechanism of scoliosis induced by forward head posture.
Spinous processes (SP) line deviating from the midline was suggested as another high risk factor for scoliosis. SP line is usually used as a low-cost, easy to use, radiation free method during family screening for scoliosis. It’s also reported that it is important to monitor the spine trunk deviation when a person is standing straight, because it can indicate whether or not the subject has orthopathology . Thus, external auditory meatus and acromioclavicular joint not in the same vertical line and deviation of SP line can be considered as important indicators for monitoring and prevention strategies of scoliosis.
Furthermore, the SFMA is a standardized movement assessment tool intended to provide a systematic process to identify the best possible therapeutic and corrective treatment program for patients. In our study, we analyzed correlation among SFMA, posture assessment and scoliosis (Table 3). Result showed that rounded-shoulder was related to limitation of active cervical rotation. Rounded-shoulder posture is characterized by a protracted, downwardly rotated, and anteriorly tipped scapula position with increased cervical lordosis and upper thoracic kyphosis . Rounded-shoulder was results from loss of lower trapezius and serratus anterior activity, tightness in the pectoralis minor, which can easily cause the overuse of the upper trapezius muscle, which affects the contralateral rotation of the cervical spine. Thus, using SFMA, we can find abnormality of cervical rotation of college students with rounded-shoulders. Physical therapist can treat cervical rotation related muscles to correct the round shoulder posture. It has been proved that the posterior tilting exercise after pectoralis minor stretching is the most effective method for eliciting greater lower trapezius and serratus anterior muscle activation . Due to the tight connection between scoliosis and abnormalities of cervical rotation and multi-segment spine extension (Table 4), correcting these abnormalities may help reduce the chance of scoliosis.