{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,8]],"date-time":"2025-12-08T16:39:29Z","timestamp":1765211969903,"version":"3.46.0"},"reference-count":32,"publisher":"MDPI AG","issue":"23","license":[{"start":{"date-parts":[[2025,12,2]],"date-time":"2025-12-02T00:00:00Z","timestamp":1764633600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Low back pain (LBP) profoundly impacts daily life, requiring assessment tools that capture its complex effects on the body and mind. This study explores a measurement tool designed to assess LBP disability, testing whether Exploratory Structural Equation Modeling (ESEM) better reveals its multidimensional nature compared to Confirmatory Factor Analysis (CFA). Methods: We analyzed data from 266 LBP patients using CFA and ESEM. The tool, developed from the items from existing scales, included 99 questions on body functions, activities, and participation. Using Mplus 8 software, we compared model fit and item connections. Results: Two main factors; \u201cBody Functions\u201d and \u201cActivity-Participation\u201d identified by CFA were tested using ESEM. While ESEM had slightly better fit compared to CFA model, many items linked across both factors which shows how pain and emotions overlap with daily activities. These results align with the International Classification of Functioning, Disability and Health (ICF) and reflect LBP\u2019s broad impact. Conclusions: ESEM offers a broader understanding of LBP\u2019s multidimensional nature compared with CFA, guiding clinicians to create a holistic management approach that address physical and psychosocial challenges. This preliminary study supports the use of ESEM in disability research, demonstrating its usefulness in identifying the multifaceted nature of LBP, therefore providing a broader perspective for assessment and management.<\/jats:p>","DOI":"10.3390\/jcm14238551","type":"journal-article","created":{"date-parts":[[2025,12,8]],"date-time":"2025-12-08T16:20:29Z","timestamp":1765210829000},"page":"8551","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Re-Examining the Dimensionality of a Disability Assessment Tool Using Exploratory Structural Equation Modeling (ESEM): A Preliminary Study in Low Back Pain"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9428-3002","authenticated-orcid":false,"given":"Serhat","family":"Hayme","sequence":"first","affiliation":[{"name":"Department of Biostatistics and Medical Informatics, Faculty of Medicine, Erzincan Binali Y\u0131ld\u0131r\u0131m University, Erzincan 24100, Turkey"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6266-3035","authenticated-orcid":false,"given":"Derya","family":"G\u00f6kmen","sequence":"additional","affiliation":[{"name":"Department of Biostatistics, Faculty of Medicine, Ankara University, Ankara 06290, Turkey"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6869-6070","authenticated-orcid":false,"given":"\u015eehim","family":"Kutlay","sequence":"additional","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Ankara University, Ankara 06100, Turkey"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7255-7535","authenticated-orcid":false,"given":"Ay\u015fe A.","family":"K\u00fc\u00e7\u00fckdeveci","sequence":"additional","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Ankara University, Ankara 06100, Turkey"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,2]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1038\/s41572-018-0052-1","article-title":"Low back pain","volume":"4","author":"Vlaeyen","year":"2018","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1732","DOI":"10.1056\/NEJMcp2032396","article-title":"Nonspecific low back pain","volume":"386","author":"Chiarotto","year":"2022","journal-title":"N. Engl. J. Med."},{"key":"ref_3","unstructured":"GBD 2021 Low Back Pain Collaborators (2023). Global, regional, and national burden of low back pain, 1990\u20132020, its attributable risk factors, and projections to 2050: A systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol., 5, e316\u2013e329."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1007\/s00586-019-06279-5","article-title":"Low back pain: Critical assessment of various scales","volume":"29","author":"Garg","year":"2020","journal-title":"Eur. Spine J."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Elhan, A.H., \u00d6ztuna, D., Kutlay, \u015e., K\u00fc\u00e7\u00fckdeveci, A.A., and Tennant, A. (2008). An initial application of computerized adaptive testing (CAT) for measuring disability in patients with low back pain. BMC Musculoskelet. Disord., 9.","DOI":"10.1186\/1471-2474-9-166"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e031749","DOI":"10.1136\/bmjopen-2019-031749","article-title":"Examining the effects of low back pain and mental health symptoms on healthcare utilisation and costs: A protocol for a population-based cohort study","volume":"9","author":"Wong","year":"2019","journal-title":"BMJ Open"},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Froud, R., Patterson, S., Eldridge, S., Seale, C., Pincus, T., Rajendran, D., Fossum, C., and Underwood, M. (2014). A systematic review and meta-synthesis of the impact of low back pain on people\u2019s lives. BMC Musculoskelet. Disord., 15.","DOI":"10.1186\/1471-2474-15-50"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1016\/j.jclinepi.2017.11.005","article-title":"A systematic review highlights the need to investigate the content validity of patient-reported outcome measures for physical functioning in patients with low back pain","volume":"95","author":"Chiarotto","year":"2018","journal-title":"J. Clin. Epidemiol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"694","DOI":"10.1097\/j.pain.0000000000001751","article-title":"What is usual care for low back pain? A systematic review of health care provided to patients with low back pain in family practice and emergency departments","volume":"161","author":"Kamper","year":"2020","journal-title":"Pain"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1007\/s11136-007-9183-7","article-title":"The role of the bifactor model in resolving dimensionality issues in health outcomes measures","volume":"16","author":"Reise","year":"2007","journal-title":"Qual. Life Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"116","DOI":"10.1080\/10705511.2014.961800","article-title":"A bifactor exploratory structural equation modeling framework for the identification of distinct sources of construct-relevant psychometric multidimensionality","volume":"23","author":"Morin","year":"2016","journal-title":"Struct. Equ. Model."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"397","DOI":"10.1080\/10705510903008204","article-title":"Exploratory structural equation modeling","volume":"16","author":"Asparouhov","year":"2009","journal-title":"Struct. Equ. Model."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1146\/annurev-clinpsy-032813-153700","article-title":"Exploratory structural equation modeling: An integration of the best features of exploratory and confirmatory factor analysis","volume":"10","author":"Marsh","year":"2014","journal-title":"Annu. Rev. Clin. Psychol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1621","DOI":"10.1097\/BRS.0000000000001563","article-title":"Structural equation model of disability in low back pain","volume":"41","author":"Melton","year":"2016","journal-title":"Spine"},{"key":"ref_15","unstructured":"\u00d6ztuna, D. (2008). An Application of Computerized Adaptive Testing in the Evaluation of Disability in Musculoskeletal Disorders. [Ph.D. Thesis, Ankara University]."},{"key":"ref_16","unstructured":"Hayme, S. (2021). Evaluation of Measurement Tools\u2019 Dimensionality Structure with the Methods Based on Structural Equation Modeling. [Ph.D. Thesis, Ankara University]."},{"key":"ref_17","unstructured":"World Health Organization (2001). ICF: International Classification of Functioning, Disability and Health, WHO."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1080\/16501960410016037","article-title":"ICF Core Sets for low back pain","volume":"36","author":"Cieza","year":"2004","journal-title":"J. Rehabil. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"E454","DOI":"10.1097\/01.brs.0000222141.61424.f7","article-title":"The Oswestry disability index, the Roland-Morris disability questionnaire, and the Quebec back pain disability scale: Translation and validation studies of the Iranian versions","volume":"31","author":"Mousavi","year":"2006","journal-title":"Spine"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2940","DOI":"10.1097\/00007632-200011150-00017","article-title":"The Oswestry disability index","volume":"25","author":"Fairbank","year":"2000","journal-title":"Spine"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"3115","DOI":"10.1097\/00007632-200012150-00006","article-title":"The Roland\u2013Morris disability questionnaire and the Oswestry disability questionnaire","volume":"25","author":"Roland","year":"2000","journal-title":"Spine"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Morin, A.J., Myers, N.D., and Lee, S. (2020). Modern factor analytic techniques: Bifactor models, exploratory structural equation modeling (ESEM), and bifactor-ESEM. Handbook of Sport Psychology, John Wiley & Sons.","DOI":"10.1002\/9781119568124.ch51"},{"key":"ref_23","unstructured":"Hayme, S. (2015). The Evaluation of Measurement Equivalence via Multiple Group Analysis and Rasch Analysis. [Master\u2019s Thesis, Ankara University]."},{"key":"ref_24","unstructured":"Brown, T.A. (2015). Confirmatory Factor Analysis for Applied Research, Guilford Publications."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1080\/00223891.2015.1089249","article-title":"Applying bifactor statistical indices in the evaluation of psychological measures","volume":"98","author":"Rodriguez","year":"2016","journal-title":"J. Pers. Assess."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"457","DOI":"10.2519\/jospt.2022.10802","article-title":"Roland-Morris Disability Questionnaire, Oswestry Disability Index, and Quebec Back Pain Disability Scale: Which has superior measurement properties in older adults with low back pain?","volume":"52","author":"Jenks","year":"2022","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1186\/s13643-018-0742-5","article-title":"Older adult\u2019s experience of chronic low back pain and its implications on their daily life: Study protocol of a systematic review of qualitative research","volume":"7","author":"Wong","year":"2018","journal-title":"Syst. Rev."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e48","DOI":"10.1017\/SJP.2020.46","article-title":"Using exploratory structural equation modeling (ESEM) to examine the internal structure of posttraumatic stress disorder symptoms","volume":"23","author":"Fresno","year":"2020","journal-title":"Span. J. Psychol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"578","DOI":"10.1097\/01.brs.0000201293.57439.47","article-title":"Minimal clinically important change for pain intensity, functional status, and general health status in patients with nonspecific low back pain","volume":"31","author":"Ostelo","year":"2006","journal-title":"Spine"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1159","DOI":"10.1007\/s11136-018-1829-0","article-title":"COSMIN methodology for evaluating the content validity of patient-reported outcome measures: A Delphi study","volume":"27","author":"Terwee","year":"2018","journal-title":"Qual. Life Res."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1002\/mpr.1485","article-title":"Exploring sources of construct-relevant multidimensionality in psychiatric measurement: A tutorial and illustration using the Composite Scale of Morningness","volume":"25","author":"Morin","year":"2016","journal-title":"Int. J. Methods Psychiatr. Res."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"3270","DOI":"10.1080\/09638288.2020.1851783","article-title":"A critical review of the biopsychosocial model of low back pain care: Time for a new approach?","volume":"44","author":"Mescouto","year":"2022","journal-title":"Disabil. Rehabil."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/23\/8551\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,8]],"date-time":"2025-12-08T16:35:00Z","timestamp":1765211700000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/23\/8551"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,2]]},"references-count":32,"journal-issue":{"issue":"23","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["jcm14238551"],"URL":"https:\/\/doi.org\/10.3390\/jcm14238551","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,2]]}}}