Aesthetic improvement is one of the most relevant goals of scoliosis treatment, be it conservative or surgical Braces built according to the SPoRT concept  within a treatment regimen based on SOSORT management criteria can achieve this goal. 
We had documented, in a previous study, the efficacy of the SPoRT brace in improving aesthetics in AIS scoliosis, with the results being similar to the Risser cast after 18 months of treatment.  However, the final results were not yet available as of the beginning of the subject study. Accordingly, this is the first study to document both immediate (six months) and end-treatment aesthetic improvements using a no-cost clinical tool specifically created for this kind of evaluation, while some previous studies used high tech instruments.  The main results were achieved within the first six months of treatment, and were maintained until the end of treatment. This issue can be very relevant for the prosecution of treatment, given that a significant trunk remodelling can improve compliance by making the patient more committed to what she or he is doing. The majority of scoliosis treatment outcomes are long-term; nevertheless, such results can seem irrelevant to a young patient without pain and the real perception of a health problem who is asked to wear a rigid plastic piece in order to avoid the risk of back pain in the remote future, along with the worsening of x-ray exams and respiratory problems. On the contrary, such a patient is usually aware of the marked asymmetries of her trunk and wants to improve this aspect as soon as possible. Therefore, the immediate improvement of aesthetics can be of additional help in achieving the improvement of functional outcomes.
Other authors have documented the efficacy of braces to model the trunk deformities in AIS. Grivas interpreted the reduction of prominence as a relevant aesthetic improvement.  Koch showed that 73% of AIS patients undergoing surgery were satisfied by the aesthetic result, and that shoulder balance was statistically related to this aspect.  Buchanan reported that some surgeons noticed deformities pertaining to the side bending of the trunk and lateral shift. All these parameters are considered in the AI, since they represent the single items on which this scale is built. Moreover, in TRACE we have added the item "hemithorax" as it relates to prominence,  which we know from Grivas to be very relevant in some cases. 
A previous study showed that AI was a tool of relatively low sensibility, and therefore we developed TRACE which is based on four sub-scales: shoulders, scapulae and waist (which were already present in the AI), and the hemi-thorax. However, the scores for each sub-scale were changed with respect to AI: shoulders now ranged from 0-3, waist from 0-4, scapulae from 0-2 and hemi-thorax from 0-2. From these sub-scales we calculated TRACE, using the sum of the sub-scale scores to reach a 12-point scale. These changes were based on our experience in using the AI. We could not use the latter because the data were collected prior to its development.  However, given the fact that TRACE is more sensitive, we can argue that more patients than 62% of those included have reached a clinically significant result with brace treatment.
The measures were recorded during each single clinical evaluation in a blinded way with respect to the previous ones, by looking directly at the back of patients. No photographs were used and all the records were performed by the same treating physician for each single patient. This can seem a limitation of the study, but in our opinion it is a strength. AI demonstrated an intra-observer reliability higher than the inter-observer one, so a single physician can guarantee the maximum sensitivity to changes. Moreover, being this a clinical practice study, the evaluation was made to help the clinical and therapeutic choice and not for research purposes. Finally, at the time when the measures used in this study had been taken, we did not yet consider them as a measurement tool but mainly as an indicator of the aesthetics of the patient to be used in clinical everyday practice for general purposes. All these are guarantees of the honest evaluation by the authors.
The main limitations of this study are represented by the small population included. In the future it will be useful to enlarge the population in order to look for subgroups by which to understand the factors related to aesthetic improvement. We tried a subgroup analysis but we found no differences with regards to sex, Risser sign. The population group on the base of menarche was not homogeneous and the analysis was not performed. Moreover, both AI and TRACE are only clinical scales: This can diffuse their usage during clinical practice, but they have nearly the same low sensitivity to changes. It is possible that some improvement relevant for patients was missed because of this, and for that reason new instruments are being developed and will be available and ready for testing. 
Another possible limitation is the lack of a control group. But we can say, based on natural history studies that a spontaneous improvement of the back deformities is almost unlikely to happen. 
The main strength of the paper is to be the first to document the aesthetic improvements of a brace treatment for AIS using a specific tool. These results can be achieved quite rapidly, during the first six months of treatment, giving the patient an immediate feedback and probably more motivation to continue the treatment regimen.