Cited by 608Musculoskeletal pain and rehabilitationSpine and Intervertebral Disc PathologyPregnancy-related medical research

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Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association

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George, Steven Z., Fritz, Julie M., Silfies, Sheri P., Schneider, Michael J., Beneciuk, Jason M., Lentz, Trevor A., Gilliam, John R., Hendren, Stephanie, Norman, Katherine S.·2021·Journal of Orthopaedic & Sports Physical Therapy

DOI 10.2519/jospt.2021.0304PMC PMC10508241

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Abstract

Low back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Globally, LBP is highly prevalent and a leading cause of disability. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), clinical practice guideline (CPG) for LBP. The overall objective of this update was to provide recommendations on interventions delivered by physical therapists or studied in care settings that included physical therapy providers. It also focused on synthesizing new evidence, with the purpose of making recommendations for specific nonpharmacologic treatments. J Orthop Sports Phys Ther 2021;51(11):CPG1–CPG60. doi:10.2519/jospt.2021.0304

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BackgroundMethodInfluential
An exploration of low back pain beliefs in a Northern America based general population
Ray, B. M., Kovaleski, A., Kelleran, K. J., Stilwell, P., Baraki, A., Coninx, S., & Eubanks, J. E. (2022) · Musculoskeletal Science and Practice · doi:10.1016/j.msksp.2022.102591 · Cited by 17
American Physical Therapy Association Clinical Practice Guideline Implementation for Neck and Low Back Pain in Outpatient Physical Therapy: A Nonrandomized, Cross-sectional Stepped-Wedge Pilot Study
Beneciuk, J. M., Osborne, R., Hagist, M. B., Crittenden, J., Buzzanca-Fried, K. E., Gao, H., & Wu, S. S. (2022) · Journal of Orthopaedic and Sports Physical Therapy · doi:10.2519/jospt.2022.10545 · Cited by 18
Self-citation
Multimodal abnormalities of brain function in chronic low back pain: a systematic review and meta-analysis of neuroimaging studies
Chen, X., Chen, N., Lai, P., Sun, Y., Yu, J., Xin, M., Zhu, D., Liang, F., Song, Q., Cheng, S., et al. (2025) · Frontiers in Neuroscience · doi:10.3389/fnins.2025.1535288 · Cited by 15
A Clinically-Reasoned Approach to Manual Therapy in Sports Physical Therapy
Short, S., Tuttle, M., & Youngman, D. (2023) · International Journal of Sports Physical Therapy · doi:10.26603/001c.67936 · Cited by 15
The cross-cultural adaptation, validity, and reliability of the Spanish version of the Fremantle Back Awareness Questionnaire
García-Dopico, N., de la Torre‐Luque, A., Wand, B. M., Roldán, O. V., & Sitges, C. (2023) · Frontiers in Psychology · doi:10.3389/fpsyg.2023.1070411 · Cited by 15
Telerehabilitation for the treatment in chronic low back pain: A randomized controlled trial
Villatoro-Luque, F. J., Rodríguez‐Almagro, D., Aibar‐Almazán, A., Carnero, S. F., Pecos‐Martín, D., Ibáñez‐Vera, A. J., Castro‐Martín, E., & Achalandabaso‐Ochoa, A. (2023) · Journal of Telemedicine and Telecare · doi:10.1177/1357633x231195091 · Cited by 20
“2,7 Of all of them, the scienti ﬁ c literature has shown how physical exercise provides a reduction of at least 10 points on the pain scale (0 – 100) compared to the other proven treatments.”
Effects of Lifestyle Interventions on the Improvement of Chronic Non-Specific Low Back Pain: A Systematic Review and Network Meta-Analysis
Herrero, P., Val, P., Lapuente‐Hernández, D., Cuenca‐Zaldívar, J. N., Calvo, S., & Gómez-Trullén, E. M. (2024) · Healthcare · doi:10.3390/healthcare12050505 · Cited by 19
“Recently, clinical practice guidelines for LBP [16–18] have reduced the emphasis on surgical interventions and pharmacological treatments, such as opioids [17,18], encouraging non-pharmacological interventions as first-choice treatments for CNSLBP, with the aim of empowering the individual with LBP…”
Background
Comparison of the Electromyography Activity during Exercises with Stable and Unstable Surfaces: A Systematic Review and Meta-Analysis
Batista, G. D. A., Picón, S. P. B., dos Passos, M. H. P., Calixtre, L. B., Santos, L. R. D. H., & de Araújo, R. C. (2024) · Sports · doi:10.3390/sports12040111 · Cited by 15
“Furthermore, specific strengthening of the trunk muscles is recommended to treat acute and chronic low back pain [101].”
Background
The clinical impact of pain neuroscience continuing education on physical therapy outcomes for patients with low back and neck pain
Louw, A., Puentedura, E. J., Denninger, T. R., Lutz, A. D., Cox, T., Zimney, K. J., & Landers, M. R. (2022) · PLoS ONE · doi:10.1371/journal.pone.0267157 · Cited by 16
“The most recent clinical practice guidelines for interventions for the management of LBP gave a grade of A (strong evidence) for manual therapy (thrust and non-thrust joint mobilization) in the management of both acute and chronic LBP [53].”
Background
Barriers and facilitators to physiotherapy among adult orthopedic patients at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia
Alzakri, A., Alsultan, O., Alhuqbani, M. N., Aldosari, Z. A., Alghadir, O., Aldosari, O., Alshehri, B. F., & Alsaleh, K. (2023) · Saudi Medical Journal · doi:10.15537/smj.2023.44.7.20230276 · Cited by 14
Additional effect of pain neuroscience education to spinal manipulative therapy on pain and disability for patients with chronic low back pain: a randomized controlled trial
Tavares, F. A. G., Rossiter, J. V. A., Lima, G. C. L., de Oliveira, L. G., Cavalcante, W. S., Ávila, M. A., George, S. Z., & Chaves, T. C. (2023) · Brazilian Journal of Physical Therapy · doi:10.1016/j.bjpt.2023.100555 · Cited by 18
Self-citation
A critical review of the role of manual therapy in the treatment of individuals with low back pain
Grenier, J., & Rothmund, M. (2024) · Journal of Manual & Manipulative Therapy · doi:10.1080/10669817.2024.2316393 · Cited by 20
“From the 20 CPG illustrated in Table 1, one strongly recommends (‘should use’) thrust-and non-thrust joint mobilization in patients with ALBP and CLBP [26], five do not mention SMT, and two recommend against SMT (one in patients with acute, one in patients with CLBP) [27,28].”
The Effects of Back Schools on Non-Specific Back Pain: A Systematic Review and Meta-Analysis
Hernández-Lucas, P., Leirós‐Rodríguez, R., Lopez-Barreiro, J., & Soidán, J. L. G. (2024) · Journal of Personalized Medicine · doi:10.3390/jpm14030272 · Cited by 15
“This link is likely due to the pivotal role of graded exercise and patient education in mitigating kinesiophobia [67].”
Background
Relationship of Healthy Building Determinants With Back and Neck Pain: A Systematic Review
Gherscovici, E., & Mayer, J. M. (2022) · American Journal of Health Promotion · doi:10.1177/08901171221112571 · Cited by 14
Spinal Manipulation and Clinician-Supported Biopsychosocial Self-Management for Acute Back Pain
Brønfort, G., Meier, E. N., Leininger, B. D., Schneider, M. J., Evans, R., Greco, C. M., Hanson, L., McFarland, C. E., Chou, R., Connett, J., et al. (2025) · JAMA · doi:10.1001/jama.2025.21990 · Cited by 13
Self-citation
Trends in Chiropractic Care and Physical Rehabilitation Use Among Adults with Low Back Pain in the United States, 2002 to 2018
Roseen, E. J., Patel, K. V., Ward, R. E., deGrauw, X., Atlas, S. J., Bartels, S. J., Keysor, J. J., & Bean, J. F. (2023) · Journal of General Internal Medicine · doi:10.1007/s11606-023-08438-3 · Cited by 14
“7, 8 33 Dissemination of practice guidelines specific to older adults, which endorse nonpharmacologic approaches, may also be needed.”
Insights into how manual therapists incorporate the biopsychosocial-enactive model in the care of individuals with CLBP: a qualitative study
Bianchi, M., Rossettini, G., Cerritelli, F., & Esteves, J. E. (2025) · Chiropractic & Manual Therapies · doi:10.1186/s12998-025-00574-3 · Cited by 13
Prevalence of Myofascial Trigger Points in Patients with Radiating and Non-Radiating Low Back Pain: A Systematic Review
Monclús-Díez, G., Díaz‐Arribas, M. J., Fernández‐de‐las‐Peñas, C., Kosson, D., Kołacz, M., Kobylarz, M. D., Sánchez-Jorge, S., & Valera‐Calero, J. A. (2025) · Biomedicines · doi:10.3390/biomedicines13061453 · Cited by 13
“%) lack an identifiable pathoanatomical cause [9] and are classified as non-specific.”
Derivation of clinical prediction rules for identifying patients with non-acute low back pain who respond best to a lumbar stabilization exercise program at post-treatment and six-month follow-up
Larivière, C., Rabhi, K., Preuss, R. A., Coutu, M., Roy, N., & Henry, S. M. (2022) · PLoS ONE · doi:10.1371/journal.pone.0265970 · Cited by 13
“Participants were selected in the non-acute phase because exercise is generally considered to be more effective after the acute phase of LBP [28, 29].”
BackgroundInfluential
Advanced hydrogel therapeutics for intervertebral disc degeneration: Engineering structural–functional properties in natural and synthetic biomaterials
Chen, T., Lu, D., Wang, S., Yang, H., Fan, W., Xiao, Z., Wang, Z., Makvandi, P., Zhu, R., & Cheng, L. (2025) · Bioengineering & Translational Medicine · doi:10.1002/btm2.70059 · Cited by 12
“30 In terms of pharmacological treatment, commonly used medications include analgesics, opioid pain relievers, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and steroid drugs.”
Analyses of different prescriptions for health using artificial intelligence: a critical approach based on the international guidelines of health institutions
Campos, V. M. S., Prudente, T. P., Leão, L. L., Costa, M., Oliva, H. N. P., & Monteiro-Júnior, R. S. (2025) · Health Information Science and Systems · doi:10.1007/s13755-025-00368-0 · Cited by 13
Physical functioning outcome measures in the lumbar spinal surgery population and measurement properties of the physical outcome measures: protocol for a systematic review
Kowalski, K. L., Lukacs, M. J., Mistry, J., Goodman, M., & Rushton, A. (2022) · BMJ Open · doi:10.1136/bmjopen-2022-060950 · Cited by 13
Attitudes and beliefs towards low back pain (LBP) among physiotherapists in Spain
Pérez, S. E. M., González, L. L., Acevedo, I. A., Barrera, R. B., Pérez, J. L. A., Romero, E. A. S., Sosa-Reina, M. D., Pérez, I. M. M., & Villafañe, J. H. (2022) · Bulletin of Faculty of Physical Therapy · doi:10.1186/s43161-022-00112-9 · Cited by 14
“Several publications, such as the latest clinical practice guide for the treatment of LBP, reject the use of these tools as the standard of high-quality care for this patient profile [17].”
Background
Are Exercise Interventions in Clinical Trials for Chronic Low Back Pain Dosed Appropriately to Meet the World Health Organization’s Physical Activity Guidelines?
Gibbs, M. T., Hayden, J. A., Cashin, A. G., Shah, B., Gilanyi, Y. L., Natoli, A. R., Holmes, G., Ogilvie, R., Hagstrom, A. D., McAuley, J. H., et al. (2023) · Physical Therapy · doi:10.1093/ptj/pzad114 · Cited by 13
Functional Neuromyofascial Activity: Interprofessional Assessment to Inform Person-Centered Participative Care—An Osteopathic Perspective
Baroni, F., Schleip, R., Arcuri, L., Consorti, G., D’Alessandro, G., Zegarra-Parodi, R., Vitali, A. M., Tramontano, M., & Lunghi, C. (2023) · Healthcare · doi:10.3390/healthcare11212886 · Cited by 12
Finite Element Analysis of Stress Distribution and Range of Motion in Discogenic Back Pain
Cho, P. G., Yoon, S., Shin, D. A., & Chang, M. C. (2024) · Neurospine · doi:10.14245/ns.2347216.608 · Cited by 12
Effects of transcutaneous electrical nerve stimulation on pain, function, and descending inhibition in people with non-specific chronic low-back pain: a study protocol for a randomized crossover trial
Liebano, R. E., Sluka, K. A., Roy, J., Savinelli, M., Dailey, D. L., & Riley, S. P. (2024) · Trials · doi:10.1186/s13063-024-08089-7 · Cited by 14
“Research into chronic LBP treatment has demonstrated strong evidence that different types of exercise decrease pain and improve quality of life [9].”
Background
Identifying the risk of exercises, recommended by an artificial intelligence for patients with musculoskeletal disorders
Griefahn, A., Zalpour, C., & Luedtke, K. (2024) · Scientific Reports · doi:10.1038/s41598-024-65016-1 · Cited by 14
Does the Number of Comorbidities Predict Pain and Disability in Older Adults With Chronic Low Back Pain? A Longitudinal Study With 6- and 12-Month Follow-ups
Lemes, Í. R., Morelhao, P. K., Verhagen, A. P., Gobbi, C., Oliveira, C. B., Silva, N. S., Lustosa, L. P., Franco, M. R., & Pinto, R. Z. (2023) · Journal of Geriatric Physical Therapy · doi:10.1519/jpt.0000000000000400 · Cited by 11
“These interventions may include education 31 about the role of comorbidities when recovering from LBP and guideline-endorsed exercises for LBP, such as motor control and general trunk exercises, graded activity, and exposure, 32 in combination with other exercises targeting the comorbidities.”
Background
Comparison of Particulate Steroid Injection vs Nonparticulate Steroid Injection for Lumbar Radicular Pain: A Systematic Review and Meta-analysis
Kim, S., Park, J. M., Kim, Y. W., Yoon, S. Y., & Lee, S. C. (2024) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2024.01.002 · Cited by 11
Physical therapy for acute and sub-acute low back pain: A systematic review and expert consensus
Wang, X., Wang, Y., Witchalls, J. B., Han, J., Zhang, Z., Page, P., Zhu, Y., Stecco, C., Lin, J., El‐Ansary, D., et al. (2024) · Clinical Rehabilitation · doi:10.1177/02692155241229398 · Cited by 12
“18 However, most of them were published ﬁ ve years ago and new clinical evidence should be reviewed.”
Background
Effect of physical therapy timing on patient‐reported outcomes for individuals with acute low back pain: A systematic review with meta analysis of randomized controlled trials
McDevitt, A. W., Cooper, C. G., Friedrich, J. M., Anderson, D., Arnold, E. A., & Clewley, D. J. (2023) · PM&R · doi:10.1002/pmrj.12984 · Cited by 11
“39 The combined effect of these limitations makes it very difficult to analyze and interpret results.”
Background
Non-Specific Low Back Pain: An Inductive Exploratory Analysis through Factor Analysis and Deep Learning for Better Clustering
Robinault, L., Niazi, I. K., Kumari, N., Amjad, I., Menard, V., & Haavik, H. (2023) · Brain Sciences · doi:10.3390/brainsci13060946 · Cited by 11
“The Clinical Practice Guidelines for the Management of Acute and Chronic Low Back Pain provide a range of interventions for the management of low back pain, including patient education, exercise therapy, manual therapy, and psychological interventions [16].”
Background
Survey of equine veterinarians regarding primary equine back pain in the United States
Marshall-Gibson, M. E., Durham, M. G., Seabaugh, K. A., Moorman, V. J., & Ferris, D. J. (2023) · Frontiers in Veterinary Science · doi:10.3389/fvets.2023.1224605 · Cited by 11
Effects of Complex Rehabilitation Program on Reducing Pain and Disability in Patients with Lumbar Disc Protrusion—Is Early Intervention the Best Recommendation?
Tarcău, E., Ianc, D., Sîrbu, E., CIOBANU, D. I., Boca, I. C., & Marcu, F. M. (2022) · Journal of Personalized Medicine · doi:10.3390/jpm12050741 · Cited by 11
The effectiveness of telerehabilitation‐based exercise combined with pain neuroscience education for patients with facet joint arthrosis: A randomized controlled study
Okudan, B., Çelik, D., & Koban, O. (2023) · European Journal of Pain · doi:10.1002/ejp.2187 · Cited by 13
“…mobility, movement con-trol, strengthening exercises and functional exercises for patients with LBP, targeting the lumbar region, abdominal area, lower extremities, hips, and vertebral column and planned as a mixture of these exercises as recommended in the current literature (George et al., 2021).”
Method
Evaluating and Characterizing the Scope of Care for Interventions Labeled as Manual Therapy in Low Back Pain Trials: A Scoping Review
Wenger, L. E., Barrett, D. R., Rhon, D. I., & Young, J. L. (2023) · Physical Therapy · doi:10.1093/ptj/pzad178 · Cited by 10
Efficacy of Laser Acupuncture for Treatment of Chronic Low Back Pain: A Systematic Review and Meta-Analysis
Mao, X.-D., He, H., & Ding, J. (2024) · Pain Management Nursing · doi:10.1016/j.pmn.2024.05.001 · Cited by 10
Effects of combined anodal transcranial direct current stimulation and motor control exercise on cortical topography and muscle activation in individuals with chronic low back pain: A randomized controlled study
Sornkaew, K., Thu, K. W., Silfies, S. P., Klomjai, W., & Wattananon, P. (2024) · Physiotherapy Research International · doi:10.1002/pri.2111 · Cited by 10
“Motor control exercise (MCE) has been identified as an effective approach to reinstating optimal movement control (George et al., 2021).”
InfluentialSelf-citation
Are Tailored Interventions to Modifiable Psychosocial Risk Factors Effective in Reducing Pain Intensity and Disability in Low Back Pain? A Systematic Review with Meta-Analysis of Randomized Trials
Rabiei, P., Keough, C., Patricio, P., Côté‐Picard, C., Desgagnés, A., & Massé‐Alarie, H. (2025) · Journal of Orthopaedic and Sports Physical Therapy · doi:10.2519/jospt.2025.12777 · Cited by 11
The design and rationale of the Biomarkers for Evaluating Spine Treatments trial: a sequential multiple assignment randomized trial
Mauck, M. C., Barth, K. S., Bell, K. M., Brooks, A. K., Chadwick, A. L., Gunn, C. A., Hurley, R. W., Ivanova, A., Piva, S. R., Schneider, M., et al. (2025) · Pain Medicine · doi:10.1093/pm/pnaf032 · Cited by 10
Self-citation
Agreement between high-quality clinical practice guidelines in their treatment recommendations for low back pain: a systematic review
McKenzie, B. J., Haas, R., Ferreira, G. E., Gorelik, A., Cyril, S., Han, J. X., Gilbert, S. E., Grobler, L., Maher, C. G., & Buchbinder, R. (2025) · The Spine Journal · doi:10.1016/j.spinee.2025.07.015 · Cited by 11
Exercise Therapy Versus Manual Therapy for the Management of Pain Intensity, Disability, and Physical Function in People With Chronic Low Back Pain: A Systematic Review With Meta‐Analysis and Meta‐Regression
González‐Gómez, L., Moral-Muñoz, J. A., Rosales‐Tristancho, A., Cuevas‐Moreno, A., Cardellat‐González, M., & Rodríguez‐Domínguez, Á. (2025) · European Journal of Pain · doi:10.1002/ejp.70090 · Cited by 12
“ET and MT have been proposed as potential noninvasive interventions for the management of CLBP, albeit with limited evidence of low-to moderate-quality (Furlan et al. 2015; George et al. 2021; Hayden, Ellis, Ogilvie, et al. 2021; Qaseem et al. 2017).”
Clinical Guidelines to Address Low Back Pain: Using the Evidence to Guide Physical Therapist Practice
(2021) · Journal of Orthopaedic and Sports Physical Therapy · doi:10.2519/jospt.2021.0507 · Cited by 10
“5 This CPG is a continuation of the 2012 LBP CPG and again emphasizes nonpharmacologic interventions to improve the quality of care and outcomes for patients with LBP.”
Background
The effect of exercise engagement on low back disability at 12-months is mediated by pain and catastrophizing in a community sample of people with chronic low back pain
Marshall, P. W., Morrison, N. M. V., Gibbs, M. T., & Schabrun, S. M. (2022) · Behaviour Research and Therapy · doi:10.1016/j.brat.2022.104205 · Cited by 10
Work-Related, Non-Specific Low Back Pain among Physiotherapists in France: Prevalence and Biomechanical and Psychosocial Risk Factors, as a Function of Practice Pattern
Pellissier, B., Sarhan, F., & Telliez, F. (2023) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph20054343 · Cited by 10
Attitudes and beliefs of Brazilian physical therapists about chronic nonspecific low back pain and its impact on clinical decision-making: An Online Survey Study
Ferreira, L. S., Silva, M. P. M. E., Saragiotto, B. T., & Magalhães, M. O. (2023) · Musculoskeletal Science and Practice · doi:10.1016/j.msksp.2023.102832 · Cited by 10
Bibliometric Analysis of Research Trends on Manual Therapy for Low Back Pain Over Past 2 Decades
Huang, L., Li, J., Xiao, B., Tang, Y., Huang, J., Li, Y., & Fang, F. (2023) · Journal of Pain Research · doi:10.2147/jpr.s418458 · Cited by 10
“As a non-invasive non-pharmacological therapy, MT is widely used in the treatment of LBP due to its recognized safety and effectiveness.(9) MT encompasses massage, bone setting, chiropractic manipulation, joint mobilization, among others.”

Authors: George, S. Z., Fritz, J. M., Silfies, S. P., Schneider, M. J., Beneciuk, J. M., Lentz, T. A., Gilliam, J. R., Hendren, S., & Norman, K. S.
ORCID: George, Steven Z.
Fritz, Julie M.
Silfies, Sheri P.
Schneider, Michael J.
Beneciuk, Jason M.
Lentz, Trevor A.
Gilliam, John R.
Hendren, Stephanie
Norman, Katherine S.
Venue: Journal of Orthopaedic & Sports Physical Therapy
Publisher: Journal of Orthopaedic & Sports Physical Therapy (JOSPT)
Published: 2021-11
Volume: 51
Issue: 11
Pages: CPG1-CPG60
ISSN: 0190-6011 (ISSN-L)
1938-1344
DOI: 10.2519/jospt.2021.0304
PMC: PMC10508241
OpenAlex: W3208162845
Cited by: 607
References: 171
Citations by year: 2026: 127 · 2025: 138 · 2024: 143 · 2023: 136 · 2022: 58 · 2021: 4
FWCI: 50.16
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Licence: other-oa
Locations: Journal of Orthopaedic and Sports Physical Therapy (publishedVersion)
PubMed (publishedVersion)
PubMed Central (acceptedVersion, other-oa)
Funders: American Physical Therapy Association
National Institutes of Health
National Institute of General Medical Sciences (T32GM081740, T32GM145226)
Topics: Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
Health Sciences › Medicine › Orthopedics and Sports Medicine › Spine and Intervertebral Disc Pathology
Health Sciences › Medicine › Obstetrics and Gynecology › Pregnancy-related medical research
Keywords: low back pain, acute low back pain, chronic low back pain, physical therapy intervention, non-pharmacological treatment, musculoskeletal pain, disability
MeSH terms: Humans, Low Back Pain, Physical Therapy Modalities, Chronic Pain, Physical Therapists

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Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association

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