Validity, Diagnostic Accuracy and Clinical Utility of Persian CPOT-Neuro in Brain-Injured Patients.

PURPOSE: Effective pain management in intensive care units (ICUs) is essential, particularly for brain-injured patients who are often unable to self-report pain. This study aimed to translate, culturally adapt, and validate the Persian version of the Critical Pain Observational Tool-Neuro (CPOT-Neuro) in brain injured patients and evaluate its diagnostic accuracy and clinical utility.

DESIGN

Prospective diagnostic accuracy.

METHODS

This study was conducted in northern Iran from 2023 to 2024. After translating and culturally adapting the CPOT-Neuro, its reliability was assessed via inter-rater and intra-rater agreement. Discriminative validity was evaluated by enrolling 132 brain-injured patients and comparing CPOT-Neuro scores before, during, and after nociceptive and non-nociceptive procedures. Criterion validity was evaluated by correlating CPOT-Neuro scores with patients' self-reported pain (when communicable). Diagnostic accuracy was examined using receiver operating characteristic (ROC) curve analysis, and clinical utility calculated using Mitchell's formula.

RESULTS

A strong positive correlation was observed between self-reported pain and CPOT-Neuro scores during nociceptive procedures (rs = 0.79, p < 0.001). The CPOT-Neuro demonstrated excellent discriminative validity, with significantly higher scores during nociceptive procedures versus rest periods (Wilcoxon Z = -9.43, p < 0.001). Inter-rater reliability during nociceptive procedures (ICC [2,1] = 0.87, 95% CI [0.69-0.95] p < 0.001) and intra-rater reliability (ICC[3,1] = 0.90, 95% CI [0.76-0.96] p < 0.001) were excellent. The Persian CPOT-Neuro revealed AUCs of 0.85 (cutoff ≥1: 94% sensitivity, 62% specificity), 0.89 (cutoff ≥3: 73% sensitivity, 91% specificity), and 0.94 (cutoff ≥5: 62% sensitivity, 98% specificity), establishing reliable cutoffs for pain-free, mild, and moderate pain identification. Positive clinical utility of Persian CPOT-Neuro for pain detection was excellent (0.85), while negative clinical utility was poor (0.48).

CONCLUSIONS

The Persian CPOT-Neuro demonstrates strong validity, reliability, diagnostic accuracy, andexcellent positive clinical utility for pain assessment in brain-injured patients, though it's negative clinical utility is limited. It is a promising tool for pain diagnosis in this population. The poor negative clinical utility suggests that a score below the cutoff should not be used in isolation to rule out pain, emphasizing the need for continued clinical vigilance.

IMPLICATIONS FOR CLINICAL PRACTICE: By embedding CPOT-Neuro into routine ICU workflows, nurses can advance evidence-based, patient-centered care and mitigate the adverse outcomes of unrelieved pain in this vulnerable population.