Abstract: Background: Pain assessment in critically ill patients with acquired brain damage and disorders of consciousness is challenging. Aim: To evaluate the content validity of an adapted version of the Behavioural Indicators of Pain Scale (Spanish: Escala de Conductas Indicadoras de Dolor [ESCID]) in patients with acquired brain damage, disorders of consciousness and an artificial airway. Study Design: Modified e-Delphi study. Five rounds of e-Delphi study to assess the content validity of the ESCID were conducted. Ten experienced clinical experts specialized in the area of interest were recruited. The starting point for the e-Delphi study was a questionnaire containing 30 behavioural indicators of pain. The expert panel evaluated the content validity of the 30 items based on four criteria: relevance, pertinence, clarity and usefulness. Each criterion was scored on a Likert-type scale ranging from 1 "strongly disagree" to 5 "strongly agree". Upon completion of all five e-Delphi rounds, a face validity test was performed. Results: Of the initial 30 behavioural indicators, 10 remained after the final round. These items were defined and categorized and included in the final version of the instrument. The degree of consensus among the experts was high with regard to the content validity of these 10 indicators. In terms of face validity, 70% of the experts considered that the writing and comprehensibility of nine of the 10 items was "good". Conclusions: A strong consensus was reached by the expert panel through the e-Delphi technique. The 10 items represent the content of the behavioural response to pain in this population. Relevance to Clinical Practice: This study is the first step to adapt Behavioural Indicators of Pain Scale for use in this patient population. This adapted scale will provide clinicians with a specific tool to improve pain detection and management.

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