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Validity, Diagnostic Accuracy and Clinical Utility of Persian CPOT-Neuro in Brain-Injured Patients
Melika Kavyanicherati1, Saeed Barzegari2, Hamid Sharif-Nia3
1Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran.
Purpose:
Effective pain management in intensive care units (ICUs) is essential, particularly for braininjured 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 braininjured 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.
