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Pain is a common symptom in the intensive care unit (ICU). Brain-injured patients are often unable to reliably self-report their pain, calling forth the need to use behavioral scales such as the Critical-Care Pain Observation Tool (CPOT). This study aimed to test the reliability and validity of the CPOT use with brain-injured ICU adults.Eight trained staff nurses and a medical student scored the CPOT before and during a nonpainful (ie, gentle touch) and at least 1 painful (eg, turning) procedure. Then, communicative patients self-reported their pain using yes/no and, when possible, on a 0 to 10 Faces Pain Thermometer.A total of 79 brain-injured ICU patients participated. The intraclass correlation coefficient between trained raters was 0.73 (95% confidence interval, 0.57-0.83) during turning. CPOT scores were significantly higher during turning compared with gentle touch (P< .001) and correlated significantly with self-reports of pain intensity during turning (0.64, P< .01). The receiver operating characteristics curve indicated a cutoff of 2 with a sensitivity of 0.90 and specificity of 0.67.Overall, the CPOT use was found to be reliable and valid in this patient group and is new evidence fulfilling an important gap highlighted in the Society of Critical Care Medicine practice guidelines.