Paper discussed: Peirce C et al. Randomised controlled trial comparing early home biofeedback physiotherapy with pelvic floor exercises for the treatment of third-degree tears (EBAPT Trial). BJOG 2013;120:1240–1247.

Location: Twitter and the RCOG World Congress 2013.

Date of journal club: 25 June 2013.

Number of participants: 35.

Number of tweets: 150.

Paper summary:

ParticipantsPrimiparous women who sustained primary third-degree tears during childbirth
InterventionEarly biofeedback physiotherapy (using a portable machine)
ComparisonPelvic floor exercise education
OutcomesPrimary: differences in anorectal manometry at 3 months postpartum. Secondary: Cleveland clinic continence scores and Rockwood faecal incontinence qualify-of-life scale scores
Study designRandomised trial (1 : 3 ratio)
FindingsNo additional benefit with early biofeedback physiotherapy

Research literacy

Randomisation in 1 : 3 ratio: unequal randomisation was a reasonable method when only a limited number of biofeedback machines were available. However, this was not detailed in the initial registered protocol, when ideally it should have been.


Choice of primary outcome

Anorectal manometry measurements can be subjective, which might confer measurement bias in an unblinded trial. Although using faecal incontinence as the primary outcome has direct clinical relevance, this may inflate the required sample size as this symptom is relatively uncommon.

The use of patient-reported outcome measures (PROMs)

The quality of the PROMs used in this trial was not consistent. Appraisal of health measurement instruments (COSMIN, should be an integral element of study design.

Length of follow-up and compliance to treatment

Although results of longer follow-up would be desirable, the current study showed that even at 3 months postpartum treatment compliance was suboptimal. Treatment compliance is likely to be poorer outside clinical trial settings, which would further compromise any potential benefits of biofeedback physiotherapy.

Take-home messages

Early home biofeedback physiotherapy did not prevent adverse sequelae of third-degree tears. Compliance with treatment was poor even during the early postpartum period.


We are grateful for all tweets. For the Storify summary and the list of contributors, please go to

  • EYL Leung

  • Women's Health Research Unit, Queen Mary, University of London, London, UKAbout #BlueJC: For an introduction to #BlueJC, please refer to BJOG 2013;120:657–660. Further information is available on Follow @BJOGTweets to join the next #BlueJC. Queries should be sent to

About #BlueJC: for an introduction to #BlueJC, please refer to BJOG 2013;120:657–660. Further information is available on Follow @BJOGTweets to receive updates for the next #BlueJC and BJOG news. Queries should be sent to