Current Physical Medicine and Rehabilitation Reports (2020) 8:322–328

https://doi.org/10.1007/s40141-020-00292-2

SPORTS MEDICINE REHABILITATION (BJ LIEM AND B KRABAK, SECTION EDITORS)

Role of Exercise Treatment of Low Back Pain in Pregnancy

Heidi Chen 1 & Gerard D’Onofrio 1 & Farah Hameed 2

Accepted: 3 September 2020 / Published online: 29 September 2020

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Purpose of Review This review identified exercise therapies for specific diagnoses underlying pregnancy-related low back
(PLBP) and pelvic girdle pain (PPGP). We describe the biomechanical changes that may lead to sacroiliac dysfunction during
pregnancy, pubic symphysis dysfunction, diastasis recti in the peripartum period, and pregnancy-related low back pain. Our
focus was to examine the impact of exercise on each condition.
Recent Findings We consolidated updated guidelines for physical activity throughout pregnancy, explored whether exercise is
effective for stabilizing the low back and pelvic girdle in pregnant and postpartum patients as well as reviewed the absolute and
relative contraindications to physical activity during pregnancy.
Summary PLBP and PPGP stem from multiple etiologies and can affect women during their pregnancy and in the postpartum
period. Exercise during pregnancy is recommended for the cardiorespiratory fitness of pregnant women, appears to reduce
disability and sick leave from work, and is considered to be relatively safe except for noted contraindications.

Keywords Pregnancy pelvic girdle pain . Pregnancy low back pain . Exercise in pregnancy and postpartum . Diastasis recti
abdominis . Pubic symphysis dysfunction . Sacroiliac dysfunction in pregnancy and postpartum

Introduction
Pregnancy related lumbo-pelvic pain (PLPP) is a common
ailment during pregnancy with physical, psychosocial, and
even economic consequences. Overall prevalence of PLPP is
variable with reports as high as 75% and as low as 20% when
excluding mild cases; most studies have reported a prevalence
of approximately 50% during pregnancy [1–4, 5••]. This dis-
crepancy in prevalence is thought to be due to heterogeneity in
defining PLPP. For the purposes of this review, PLPP is an
umbrella term encompassing the area between the twelfth rib
This article is part of the Topical Collection on Sports Medicine
Rehabilitation
* Farah Hameed
fh2282@mail.cumc.columbia.edu
1 er back pain with menses [1, 2, 7, 8].
NewYork-Presbyterian, Rehabilitation and Regenerative Medicine,
Columbia University Medical Center, Weill Cornell Medical Center,
New York, NY, USA
2
Rehabilitation and Regenerative Medicinen, Columbia University
Medical Center, 180 Fort Washington Avenue, New
York, NY 10032, USA
and the gluteal fold that can be delineated into two patterns of
pain: pregnancy-related lower back pain (PLBP) and
pregnancy-related pelvic girdle pain (PPGP) [1]. PLBP is con-
sidered to be pain located between the twelfth rib and iliac
crest. PPGP is considered pain between the posterior iliac
crest and gluteal fold encompassing the pelvis; this is further
subcategorized into 4 classes depending on localization of
pain: anterior in the pubic symphysis, posterior in either sa-
croiliac joint, both sacroiliac joints, and complete pelvic girdle
syndrome with involvement of all pelvic joints [6].
Risk factors for PLPP have been studied extensively with
several studies concurring that prior history of lower back
pain, heavy workload, and increasing parity increased the
odds of developing PLBP and/or PPGP [1, 3, 7]. Other factors
that have inconsistently been shown to be significant risk fac-
tors include maternal weight, BMI, family history of PLBP
and PPGP during pregnancy, oral contraceptive use, and low-
PLPP can prevent pregnant women from performing their
activities of daily living and interfering with quality of life. Of
women with PLPP during pregnancy, approximately 45%
have mild symptoms, 25% have more serious pain, and 8%
are severely disabled [1]. Of women with PLPP postpartum,
Curr Phys Med Rehabil Rep (2020) 8:322–328
approximately 80% have mild symptoms, and 7% have severe
symptoms [1]. Comorbidities associated with PLPP include
sleep disturbances, increased stress, and anxiety throughout
pregnancy. As patients progress through their pregnancy
course, their symptoms can worsen which has been shown
to lead to an increased sick leave from work due to debilitating
pain [9••].
Pathophysiology
The exact pathophysiology of PLPP remains unclear; though,
it is widely considered to be multifactorial due to biomechan-
ical and hormonal changes during pregnancy. Briefly, biome-
chanical changes result from an enlarging gravid uterus and
the lengthening and separation of the abdominal muscles
causing postural compensations and a shift in the center of
gravity culminating in PLPP. The enlarging uterus shifts the
center of mass superiorly and anteriorly which directly trans-
lates into a changed line of gravity while standing resulting in
an exaggerated lumbar lordosis as well as rotation of the pelvis
on the femur [10, 11]. Consequently, the erector spinae mus-
cles work harder in order to maintain an upright posture [12].
These postural changes are further influenced by hormonal
changes that occur throughout the course of pregnancy, such
as upregulation of relaxin and other hormones, which alters
the mechanical stability of the SI joint(s) and pubic symphysis
[13, 14]. This ligamentous laxity creates an increased range of
movement in the pelvic joints which may result in pain if there
is no corresponding increase in neuromotor control [3].
History and Assessment of PLBP and PPGP
It is important to delineate whether the patient has PLPP in the
initial assessment to guide treatment. Onset of PLPP has been
recorded as early as the end of the first trimester up to the first
month postpartum with average onset at 18 weeks gestation
[1]. Pain intensity has been studied to peak between 24 and
36 weeks.
The characteristics of pain and several provocative physical
exam maneuvers may provide guidance on distinguishing be-
tween PLBP and PPGP. PLBP is typically described as a dull,
achy, tight in the lumbar region with exam findings of restrict-
ed motion of forward flexion in the lumbar spine and
paraspinal muscular tenderness that closely resembles lower
back pain in a nonpregnant state. Exam maneuvers that may
provoke pain include midline or paraspinal tenderness, pain
with lumbar range of motion, straight leg raise (SLR), or
seated slump test.
PPGP is typically described as stabbing, shooting, dull, or
burning pain without restriction of lumbar spine movement. If
involving the sacroiliac joint(s), the pain can be isolated in the
323
upper gluteal/buttock region and can radiate towards the foot
in some cases. Pain provocative exam maneuvers evaluating
the sacroiliac joint include the posterior pelvic pain provoca-
tion test (P4), Patrick’s FABER (flexion, abduction, external
rotation of the hip), compression test, Gaenslen’s test, and
palpation of the long dorsal ligament. The active straight leg
raise (ASLR) is also commonly used to evaluate for PPGP as
it identifies ability to transfer loads from the lumbar spine into
the pelvic girdle [15]. Of these, P4, ASLR, and FABER have
the greatest reported sensitivity and specificity [3].
Some of the most common symptoms women experience
with pubic symphysis dysfunction are sharp, stabbing pain in
the pubic region, groin, and medial aspect of the thigh. These
symptoms are typically exacerbated by weight-bearing activ-
ities and may result in a clicking sensation in the pelvis, as
well as a compensated waddling gait pattern [16]. The modi-
fied Trendelenberg and palpation of the pubic symphysis are
exam maneuvers that can localize the pain generator to the
pubic symphysis [3]. ASLR can also increase pain from the
pubic symphysis. Generally hip range of motion is main-
tained, and physical examination tests evaluating for
intraarticular hip pathology are negative.
Current literature utilizes variable definitions for PLPP, and
studies do not consistently delineate a difference between
PLBP and PPGP, even though they can be distinguished di-
agnostically and are indeed distinct entities. Despite this, re-
search in exercise in pregnancy is continuously evolving, and
there is some evidence that PLBP and PPGP symptomatology
may be improved with exercise. Here, we discuss the specific
exercises that can be implemented to target these specific
conditions.
Sacroiliac Joint Dysfunction in Pregnancy
Sacroiliac joint pain in pregnant women results from increased
joint stress due to an anterior and superior shift in center of
gravity and increased pelvic laxity. Furthermore, dysfunction
of load transfer in the lumbopelvic region has been raised to be
an explanation of lumbopelvic pain [15]. In particular, asym-
metric laxity of the sacroiliac joint is associated with moderate
to severe pain [17].
Exercise Therapy
A well-regarded theoretical model of lumbopelvic pain dem-
onstrates the self-locking mechanism of the pelvic joints based
on the principles of form closure and force closure [18]. The
local stabilizing muscles, i.e., the transversus abdominus, the
lumbar multifidus, and the pelvic floor muscles, as well as
activation of diagonal trunk musculature are reported to play
an important role in load transfer in the lumbopelvic region
[19, 20]. In addition to the musculature described above,
324
sacroiliac joint shear is also influenced by force closure of
fascial structures and ligamentous tension which also have a
role in preventing sacroiliac joint pain.
Diagonal trunk muscle systems are composed of the con-
tralateral latissimus dorsi, as well as the gluteus maximus
muscle and oblique abdominals. Transversely oriented pro-
grams focus on the transversus abdominis muscles, internal
obliques, multifidi, as well as the pelvic floor, diaphragm, hip
adductors, and abductors [21]. Transverse exercise programs
are predicated upon the theory that activation of the
transversus abdominis muscle and pelvic floor decreases lax-
ity at the sacroiliac joint. The sequencing of muscle activation
is a mainstay of therapy. Exercises that specifically activate
the hamstrings may provoke sacroiliac joint pain; thus, hip
extension should be trained with focus on early activation of
the gluteus maximus. In a compensatory movement pattern,
poor sequencing of hip extensor activation may result in com-
pression or muscle imbalance, thus causing pain at the sacro-
iliac joint and altering mobility. Specific stabilizing exercises
for the local muscles that stabilize the pelvic girdle and acti-
vate the pelvic floor have been shown to be effective for
women with PPGP during pregnancy using a home exercise
program [22]. Furthermore, the effects of an individual stabi-
lization program with specific transverse exercises were dem-
onstrated to show improvement in pain scores, higher quality
of life, and lower disability up to 1-year postpartum when
compared with an exercise program without specific stabili-
zation exercises [23].
Pubic Symphysis Dysfunction in Pregnancy
Similar to the biomechanical changes that cause pain from the
sacroiliac joint, pelvic girdle instability as a result of sacroiliac
joint or symphysis instability may lead to pubic symphyseal
pain in isolation or in combination with sacroiliac joint pain.
Exercise
Exercise can improve symphysis-mediated pain through ab-
dominal and pelvic stabilization. Activation of the transversus
abdominis, external and internal oblique, and multifidi mus-
cles in conjunction with pelvic floor activation, gluteus
maximus contractions, latissimus dorsi activation, and hip ad-
ductor contractions can reduce disability and pain attributed to
pubic symphysis dysfunction in pregnancy. In women with
pregnancy-related anterior pelvic instability, symptomatology
typically resolves by 12 weeks postpartum. Appropriate posi-
tioning may also help; some women may find relief from
anterior pelvic instability when lying in the lateral decubitus
position [24].
Pelvic girdle instability, whether it originates from laxity of
the sacroiliac joint or pubic symphysis, has been addressed
Curr Phys Med Rehabil Rep (2020) 8:322–328
with the use of pelvic support belts. Belts are thought to pro-
vide a stabilizing, external force to the pelvic joints. In partic-
ular, pregnant women can experience significant relief from
use of nonelastic pelvic support belts. A three-group compar-
ison of pregnant women with pubic symphysis dysfunction
performing exercise alone, exercise with a nonrigid belt, and
exercise with a rigid belt showed that they all had significant
functional improvements with reduction in pain. While there
was no functional difference between rigid and nonrigid belts,
the two belt types and exercises help stabilize the pelvic girdle
which contributes to alleviation of symptoms [16].
Diastasis Recti in the Peripartum Period
Development and Associations
Diastasis recti abdominis (DRA) is a term describing midline
separation of the two rectus abdominis muscles along the line
of the linea alba that exceeds normal values. Variation delin-
eating cutoffs for DRA exist in the current literature. During
pregnancy, as the growing uterus produces a stretching force
on the abdominal wall, the two rectus abdominis muscles
lengthen and separate. The linea alba softens and the two
muscle bellies curve around the abdominal wall with most
separation occurring at the umbilicus [25]. This alteration in
distance between the rectus abdominis muscles has been pos-
tulated to lead to core instability and may contribute to ab-
dominal, low back, and pelvic pain [26•]. This condition may
also be associated with pelvic floor dysfunction as well as
cosmetic concerns. DRA generally recovers spontaneously
by 8 weeks postpartum. Of note, both aerobic and
resistance-based exercise may pose a benefit by decreasing
odds of developing diastasis recti when continued from the
prepregnancy period [27]. The reported prevalence of DRA
varies and may be inaccurate due to different cutoff points for
the diagnosis and use of different measurement methods. With
the use of ultrasonography, DRA was shown to persist at
6 months postpartum in 39% of women [28]. Therapeutic
exercise may be employed to alter biomechanics and approx-
imate the rectus abdominis muscles over time when DRA is
persistent.
Exercises
Knowledge regarding exercises that approximate the rectus
abdominis muscles is evolving. Physical therapy programs
traditionally include curl-ups, pelvic floor muscle (PFM) ex-
ercises, and in-drawing exercises; of which, the latter two are
most common [29]. Randomized controlled trials (RCTs)
have investigated the effect of exercise treatment in women
with DRA. However, there is no consensus on which exer-
cises are most effective due to inconsistent results, the use of
Curr Phys Med Rehabil Rep (2020) 8:322–328
different exercise interventions, different cutoff points for
DRA, and different outcome measures in the published
RCTs. Interestingly, recent experimental studies have found
more traditionally used in-drawing and PFM contraction ex-
ercises actually increase the interrecti distance (IRD), while
curl-ups have been shown to close the diastasis. In a recent
ultrasound-guided study of 38 postpartum patients with DRA,
head lift and twisted curl-up were the only exercises that sig-
nificantly decreased the IRD, both above and below the um-
bilicus [30••]. In addition, curl-up decreased the IRD, above
the umbilicus. PFM contraction, maximal in-drawing, and
maximal in-drawing plus PFM contraction actually increased
the IRD below the umbilicus [29].
There are differing theories hypothesizing whether exer-
cises used in treating DRA should include movements that
lead to an immediate increase or an immediate decrease in
IRD. Some have suggested that exercises that narrow the
IRD during abdominal maneuvers may cause permanent re-
duction of IRD; however, others argue that without activating
the transversus abdominus (TrA), there will be an increase in
the distortion of the linea alba which could interfere with an
important element in rehabilitation of DRA [28, 31]. If the
linea alba remains slackened, this has been theorized to lead
to altered force transmission through abdominal musculature
and persistent abdominal protrusion [30••]. However, whether
contraction of the TrA can have a strengthening effect on the
linea alba is a hypothesis that needs to be studied further. It is
also important to consider that training of the TrA and other
core stabilizers may also be necessary to help treat the symp-
toms of lumbopelvic pain that can be seen in patients with
DRA. At this time, there are no RCTs evaluating whether
exercises that decrease the IRD immediately lead to a perma-
nent reduction in IRD over time and a consensus has not yet
been reached on the appropriate exercises to use for DRA.
Low Back Pain
At present, exercise therapy for PLBP has not been studied
independently of PPGP as the majority of women with PLPP
likely have PPGP or a combination of PLBP and PPGP.
Overall, treatment of PLBP is noted to be similar to lower
back pain in a nonpregnant state. One study provided a “back
muscle strengthening” program for PLBP and a separate pro-
gram to avoid overloading the pelvis for PPGP which showed
improvement of both groups with their respective programs;
however, specific exercises for the therapy programs were not
provided [32]. Another study identified individualized exer-
cise therapy with the goal of improving posture, ergonomics,
spine mechanics with lifting/bending, and muscle training for
both PLBP and PPGP led to a reduction in sick leave and
improved pain postpartum for PLBP compared with PPGP
[33].
325
Other Exercise-Based Programs
Water-Based Exercise
Water-based exercise may be helpful for women with PLBP
and PPGP due to the reduction in the compressive forces on
the spine attributable to the reduced sensation of gravity in the
water. Further, water exercise may help the pregnant women
dissipate heat more effectively, thus making a preferable set-
ting for exercise. As pregnancy progresses, the effects of
water-based exercises such as water gymnastics can be bene-
ficial. Water gymnastics has been shown to significantly de-
crease the intensity of pregnancy-related low back pain as well
as decrease the number of women on sick-leave due to low
back pain [34]. Notably, engaging in water gymnastics does
not confer additional risk for urinary or vaginal infections.
Women who engage in water-based aerobics approximately
19 weeks of gestation develop less pregnancy-related low
back pain compared with women who engage in land-based
gymnastics [35].
Yoga
Yoga is a form of complementary and alternative medicine
(CAM) rooted in Hindu philosophy with postures, breath
work, and meditation. Within the USA, there is growing pop-
ularity with the use of CAM of which up to 19% of pregnant
women were found to practice yoga during pregnancy as it is
an easily modifiable form of low impact exercise. It is impor-
tant to note that supine activities are not recommended after
the 1st trimester due to the theoretical risk of reduced cardiac
output and orthostatic hypotension that can occur as the uterus
enlarges; however, there is still no concrete evidence of this
[36•]. Pregnancy-specific yoga classes avoid these types of
positions with exercise and are therefore considered
acceptable.
There are few randomized controlled studies regarding the
use of yoga during pregnancy and general limitations include
low power due to small sample sizes. Studies have reported on
decreased pain intensity in lumbar and posterior pelvic pain
with one study evaluating a 1 h a week program for 10 weeks
and another study evaluating a 3-times-a-week for 30 min
over 12 to 14 weeks [37, 38]. Another study evaluating a pilot
prenatal yoga program did not find a significant difference in
lumbar pain with the control group when using Roland Morris
Disability Questionnaire which may indicate that while a yoga
program may increase flexibility, it may not necessarily im-
prove pain symptoms if exercises to strengthen the core mus-
culature and pelvic girdle are not included [39]. Of note, cer-
tain positions in yoga may increase shear forces of an already
lax pelvic girdle which could contribute to PPGP. However,
studies regarding yoga in pregnancy have also found that pa-
tients have reduced stress, anxiety, depression, and sleep
326
disturbances [40]. Yoga postures are found to be relatively
safe when measuring both maternal and fetal responses; how-
ever, caution should be taken when incorporating hot yoga
into an exercise program [39, 41]. There are no published
studies on the safety and outcomes of hot yoga for pregnant
women and their fetuses. This is a concern because hyperther-
mia is a known environmental teratogen. In humans, an ele-
vated core body temperature has been shown to occur with
extreme exercise, hot tubs and saunas, and avoidance of these
activities during pregnancy is recommended [42].
General Exercise Considerations
Physiologic Adaptations
The physiology of pregnant women may change as a result of
increased blood volume, an increase in resting heart rate, in-
crease in stroke volume, and an overall decrease in systemic
vascular resistance. Additionally, there are increased resting
oxygen requirements due to an elevation in metabolic rate
during pregnancy. Heat production at rest increases, resulting
in a raised body temperature during exercise that is commen-
surate with the intensity of the exercise [14••]. A consideration
for nutritional requirements should be implemented due to the
fact that pregnant women preferentially metabolize carbohy-
drates at a greater rate both during rest and exercise than non-
pregnant women.
Aerobic Exercise
Aerobic exercise is considered a component of standard rec-
ommended obstetrical care for pregnant women. Physical and
psychological benefits are evident in the literature, such as
marked reductions in the development of gestational diabetes
and hypertensive disorders, alongside improvements in de-
pressive symptoms and cardiorespiratory fitness [43••].
Furthermore, regular exercise during pregnancy decreased du-
ration of total active labor [44•]. Typically, it is recommended
to improve cardiorespiratory fitness prior to labor and deliv-
ery, especially for a previously inactive woman through activ-
ities such as walking and stationary cycling. It is useful for the
pregnant patient to be able to gauge exercise intensity and
fatigue by comparing against previously exercise routines.
Activities that carry a higher risk of falling or causing ab-
dominal trauma such as downhill skiing, gymnastics, horse-
back riding, and high contact sports should be avoided during
pregnancy [14••]. Additionally, activities that can lead to rapid
physiologic changes such as scuba diving should be avoided.
Other activities that have higher impact such as jogging, run-
ning, and racquet sports should be evaluated on an individual
basis but are generally regarded to be safe in pregnancy, es-
pecially if the mother had been previously engaging in these
Curr Phys Med Rehabil Rep (2020) 8:322–328
activities prior to the pregnancy with care taken to avoid risk
of falls.
Any form of exercise will lead to heat dissipation, thus
pregnant women should take care to be hydrated prior to en-
gaging in physical activity. Exercise should be approached
with caution in excessive heat or high humidity environments
[43••]. Maintaining an appropriate energy balance to ensure
proper fetal development and offset the energy costs of exer-
cise is prudent [43••]. Frequency of exercise for pregnant
women should parallel that of nonpregnant women, with rec-
ommendations from the CDC suggesting 150 min of moderate
intensity exercise a week [14••]. Light to moderate resistance
training is considered to be safe in pregnancy and should be
encouraged twice per week [14••].
Regular leisurely physical activity appears to have a pro-
tective effect against development of low back and pelvic pain
during pregnancy. With an increasing number of years of
regular physical activity, women are less likely to develop
low back and pelvic pain. This association demonstrated that
regular leisurely activity decreases the risk of developing low
back and pelvic pain during pregnancy, although the mecha-
nism is unclear [33, 45]. Proposed mechanisms of how activ-
ity reduces the risk of PLBP and PPGP during pregnancy are
that physical activity may confer a better physical condition at
the onset of pregnancy, thus allowing women to remain active
throughout the pregnancy because they are not limited by
pain.
Ultimately, aerobic exercise alone may not be sufficient to
alleviate back pain, as evidenced by randomized controlled
trials demonstrating superiority of multimodal interventions
as compared with standard obstetrics care for pregnant women
with low back and pelvic pain [46••, 47]. For instance, tech-
niques incorporating joint mobilization, postisometric relaxa-
tion, myofascial release, and stabilization exercises targeting
the core musculature, glutei, quadratus lumborum, and other
muscles in a variety of positions have been proven to be su-
perior to a regimen comprised of standard, unsupervised ob-
stetric aerobic exercise, heat, acetaminophen, and rest [45].
Contraindications
While physical activity and exercise are beneficial during
pregnancy, it is important to remain cognizant of contraindi-
cations to exercise during pregnancy as noted in Table 1 [14,
43]. Individuals with relative contraindications should consult
with their obstetrician prior to engaging in activity.
Conclusion
PLBP and PPGP are common pain syndromes stemming from
multiple etiologies including sacroiliac joint dysfunction, pubic
Curr Phys Med Rehabil Rep (2020) 8:322–328 327

Table 1 Absolute and relative contraindications to physical activity during pregnancy

Absolute contraindications Relative contraindications Contraindications to regular exercise

during pregnancy

Ruptured membranes, premature labor Recurrent pregnancy loss Vaginal bleeding

Unexplained persistent vaginal bleeding Gestational hypertension Regular painful contractions
Placenta previa after 28th week of gestation Symptomatic anemia Amniotic fluid leakage
Preeclampsia Twin pregnancy after 28th week of Dyspnea prior to exertion
gestation
Cervical insufficiency History of spontaneous preterm birth Dizziness/syncope
Intrauterine growth restriction Eating disorder Calf pain or swelling
High-order multiple pregnancy (i.e., triplets) Malnutrition Headache
Uncontrolled type I diabetes, uncontrolled hypertension, Mild/moderate cardiovascular or Chest pain
uncontrolled thyroid disease respiratory disorders
Serious cardiovascular, respiratory, or systemic disorders Other medical conditions Muscle weakness

symphysis dysfunction, and diastasis recti abdominis, among
others. The biomechanical changes produced during pregnancy
can worsen throughout the course of pregnancy as the gravid
uterus grows and shifts the center of mass anteriorly and supe-
riorly, altered hormonal state leads to ligamentous laxity, and
underlying physiologic changes alter how biomechanical loads
are transmitted through the musculoskeletal system.
At this time, exercise during pregnancy is recommended for
the cardiorespiratory fitness of pregnant women, appears to
reduce disability and sick leave from work, and is considered
to be relatively safe except for noted contraindications. There
are various forms of exercise employed within the literature on
this topic, including land-based, aquatic, and alternative forms
of exercise such as yoga. Generally, exercise during pregnancy
should be directed at improving and sustaining the fitness of the
pregnant patient as well as strengthening the core musculature
and stabilizing the pelvis to withstand the altered biomechanics
inherent in pregnancy that may contribute to pain.
Compliance with Ethical Standards
Conflict of Interest None of the authors has any potential conflicts of
interest to disclose.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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