Soviet Psychology

ISSN: 0038-5751 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/mrpo19

Expert Evaluation and Restoration of Work

Capacity Following Brain Injuries in Combat

S. Ya. Rubinshtein

To cite this article: S. Ya. Rubinshtein (1987) Expert Evaluation and Restoration of Work
Capacity Following Brain Injuries in Combat, Soviet Psychology, 26:1, 51-59

To link to this article: http://dx.doi.org/10.2753/RPO1061-0405260151

Published online: 19 Dec 2014.

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 S . YA. RUBINSHTEIN

Expert Evaluation and

Restoration of Work Capacity
Following Brain Injuries in
Combat
A number of studies have dealt with the work capacity of people who
have suffered brain injury. After the first imperialist war, in almost
every country there were discussions concerning the dual pathogenesis
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of posttraumatic states and the relationship between functional and

organic factors in the disability resulting from such injury. The very
fact that this discussion took place reflects the circumstance that, first,
the work capacity of a human being depends not so much on the
elementary physiological premises of his activity as on attitudes, ten-
dencies, and personal motives and that, second, brain injury can, in
some cases, cause impairment and alteration in these attributes. These,
in general outline, are the conclusions of a number of authors.
Experimental psychological criteria of intellectual work capacities
were first proposed by Kraepelin. Thereafter, a multitude of isolated
intellectual and composite practical tests were proposed for a prognosis
of work capacity. Popelreuter introduced such practical tests for people
who had suffered brain injury.
Professor V. N. Myasishchev and co-workers have pointed out the
invalidity of drawing conclusions concerning work capacity on the
basis of a single test. The erroneousness of such a conclusion is a source
of faulty practice in vocational guidance. Actual work is qualitatively
different from an experimental test because the motivational structures
of the two are different. Although success in a single isolated test may
(and then only to a certain degree) characterize the technical precondi-
tions of a person’s work capacity, the productivity of actual work is
determined largely by the person and his attitudes. For qualitative

From N. I. Grashchenko (Ed.), Nevrologiya voennogo vremeni [Neurology of the

war years]. Moscow, 1949.

51
 52 S. YA. RUBINSHTEIN

analysis of the criteria of work capacity, a combination and comparison

of both factors are valuable.
The purpose and the conditions of the present study presented us
with this possibility.
In neurosurgical hospital 3120, where the last stage in the treatment
of people who have suffered brain injury takes place, practical ques-
tions of evaluating combat fitness and work capacity-and, in serious
cases, for helping patients to adapt to work-were posed long before
the patients were discharged.
To this end, we especially organized large, well-equipped workshops
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for occupational therapy (woodwork, metalwork, shoemaking, tailor-

ing, and also courses for learning bookkeeping, cooking, and writing
with the left hand). They were run by a special staff of instructors and
psychologists who were experts in methods, and were totally governed
by the ends of therapy, instruction, and expert evaluation. The attend-
ing physicians assigned the patients to the workshops. Special “quiet
hours” and special work conditions were created for the seriously ill
patients, and instruction was provided on the basis of programs offer-
ing a real possibility of acquiring a skill of the second or third category.
The purposes of workshop assignment were: (1) restoration of im-
paired functions, (2) expert evaluation and vocational consultation,
and (3) work training. These often coincided or intersected. Because of
the conditions of the wounded before they were discharged and before
they appeared before the commission, these questions were very im-
portant for the patients. For most of them, this period marked a certain
turning point in their lives, and the questions of retaining their combat
fitness and work capacity, of changing professions, and of job retrain-
ing if they were unable to return to their former work (heavy physical
labor) profoundly affected their vital interests. The value of the present
study lay in this combination of clinical evaluation of, and current life
situations surrounding, job placement, permitting data on anatomical
and physiological impairments to be compared with psychological
structures involving integral functions and individual personality traits.
Our very first experience showed that very often judgments about
work capacity made only on the basis of clinical findings were errone-
ous. The significance and relative importance of the same neurological
and psychopathological symptoms were not the same in assessing the
clinical picture as they were in assessing the patient’s general viability.
The degree and the nature of a patient’s endurance, observed fleetingly
in the hospital, often played a decisive role in his adaptation to work,
 RESTORATION OF WORK CAPACITY FOLLOWING BRAIN INJURIES 53

whereas the role of local defects, such as hemiparesis, hemianopsia,

etc., might unexpectedly prove to be negligible. There were numerous
examples of discrepancies between an isolated clinical assessment and
an evaluation based on labor expertise. It became necessary to establish
certain compound criteria.
To determine typical functional defects that reduced the work capac-
ity of our patients, we used a method of work tests combined with an
overall evaluation of the patients’ productivity and learning ability in
workshops, plus, in some cases, catamnestic data.
An analysis of the results of training and the performance of work
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tests enabled us to distinguish basic types of functional defects, which

we ranked under the following headings: (1) fatigability or endurance,
(2) instability, (3) impairment of inclination to work, and (4) locally
conditioned disruptions in the technical and practical aspects of work.
One of the most striking functional defects was fatigability or re-
duced endurance. The forms in which this was observed, and its de-
gree, varied. Some patients became more fatigued from intellectual
stress, and others, from physical stress.
Most of the patients suffering from this defect were patients with
closed cranial injury. Only a few patients with penetrating, extensive
damage of the brain matter were included in this group. In these latter
cases, fatigability was often the background against which other local
disorders developed. The attitude of this group of patients toward work
tests and work as a whole was, in a sense, unique. The psychological
status of these patients in the hospital was somewhat more complex.
Though they had no open wounds and did not suffer from any local
disorders, they often felt themselves constrained to insist upon and
assert their right to be ill. More thorough, critical investigation usually
confirmed that the patients’ complaints of headaches, malaise, and
weakness were quite well founded. The attitude of patients of this
group toward work as a whole and toward their own work training in
particular was wholly positive, very active, and very conscientious.
They were very circumspect in making their choice, made themselves
at home in one of the workshops, resolutely overcame difficulties, and
studied.
Patients with penetrating cranial wounds without, for the most part,
marked local symptoms made up the unstable group. Since the patients’
neurological condition took a favorable course, there were compara-
tively few data for functional evaluation of their work capacity. The
doctors exercised great caution in assigning them to workshops. The
 54 S. YA. RUBIMSHTEIN

time and conditions of their jobs were carefully regulated. However,

their behavior in workshops and indices of their productivity in the
most difficult jobs, requiring physical exertion and concentrated atten-
tion, disclosed no visible impairment. The functional defect that im-
paired the work capacity of these patients was their extreme variability.
Frequent and sudden breakdowns and deteriorations in their condition
put them completely out of action. Characteristic of these patients were
an absence of a subjective assessment of their capacities and a lack of
any protective defense mechanisms or of subjective fatigue.
In arranging jobs for these patients and training them, it was very
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important for them to acquire skill in a craft or trade, not in industrial

production, since it was essential for them to be able to take time off
from work periodically.
It may be assumed that the large number of cases of reduced work
capacity in patients with severe injuries that industrial medicine expert
commissions usually observe are the result not so much of injury itself
as of the influence of additional, toxic, and socially harmful factors.
Our patients, who were in favorable conditions, proved to be relatively
intact immediately after injury, even in the so-called “subacute”
stages.
The next most severe functional defect was an impaired attitude
toward work, a loss of inclination to work.
The clinical correlate of this defect was a frontal syndrome, which
may be considered to be at the borderline between general brain disor-
ders and local disorders.
That this view of this defect is correct is evidenced by the fact that
the frontal symptoms “shone through” in a large number of cases in
which the site of the injury was anywhere but frontal. Some authors
point out that the frontal cortex, which phylogenetically is quite recent,
almost always reacts to any disturbance in brain activity, and that
“frontal” disorders are to some extent general, background disorders
in many brain injuries. In our case material, this defect of personality
structures was, so to speak, the background for a variety of injuries.
However, it was also observed in its purest form in gunshot wounds of
the poles of the frontal lobes.
The symptoms of this defect involved, first and foremost, a dis-
turbed attitude toward work. The patient did not learn effectively, his
industrial activity was unproductive, and there was a high proportion
of waste and damage of materials and instruments as a result of lack of a
sense of responsibility for one’s own actions. These patients were
 RESTORATION OF WORK CAPACITY FOLLOWING BRAIN INJURIES 55

extremely frivolous and unconcerned toward their own job placement.

Catamnestic data showed extremely unfavorable conditions in their
later lives.
The neurological and psychopathological characteristics of this
group of patients were as follows. Basically, these were patients with
penetrating wounds of the frontal lobes and contiguous areas (ninth,
tenth, and eleventh fields in Brodman’s classification), uncomplicated,
and exhibiting almost no gross neurological symptoms. Because the
injury had occurred in a young healthy brain, the state of these patients
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after the healing process was completed was very favorable. The symp-
toms of their disorders were, to use Professor Shmar ’yan’s expression,
not “irritative,” but “defect related.”
In our case material we found almost no instances of euphoria and
silliness, described by many authors as a common symptom of frontal
lesions. We were able to observe only a certain placidity, owing to the
unconflicted and carefree manner of our patients, who were at the
borderline of a normal, light-hearted, “good” character. In no case did
we observe aspontaneity in the form of general inertness, listlessness,
immobility, etc., also described often in the clinical picture of frontal
lesions. One would rather say that the patients lacked initiative, had no
motivation that was “important for themselves,” and that their ac-
tions, which outwardly seemed totally appropriate, lacked meaning for
them. For example, one patient signed up for a bookkeeping course two
days before his departure, about which he was well informed, only
because his ward-mate had decided to sign up for this course. B. V.
Zeigarnik describes the disinhibitedness, the “sexual behavior,’’ of
patients with frontal lesions as being the obverse side of the coin of this
same aspontaneity.
In their structure, the deeds and actions of our patients corresponded
fully to this description, but they were less direct in terms of their form
and the degree of their manifestation. Most often, the hospital regime
was the “field” for them, and gradually became almost the only driv-
ing force of the monotonous behavior of these patients. In the same
way, any interoceptive perceptions (hunger, sexual drive, fatigue,
etc.), even when not exaggerated, became excessively imperative, un-
analyzed incentives for action. The suggestibility of these patients was
excessive: it was so easy to control these patients that their behavior in
the normally organized hospital environment was almost correct.
The picture of the patients’ defects was simple, and uncomplicated
by intercalations of the primary and secondary symptoms so usual in a
 56 S. YA. RUBINSHTEIN

psychiatric hospital. One of the most important reasons for this sim-
plicity was the fact that we observed them in the hospital at an early
stage after their injury.
It should not be thought that complex forms of conscious human
behavior depend directly on the functioning of the frontal cortex. The
latter probably provides the necessary conditions for complex mental
activity. Inappropriate behavior and a psychopathological picture are,
despite their complexity and diversity, evidently not (like other local
defects) the result of frontal lesions, but the result of the life of the
person whose brain injury is so located. This is natural, because people
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who have just been wounded and have not yet been anywhere except in
the hospital have, to a considerable extent, preserved their previous
norms and stereotypes of behavior. The hospital plays the role of a bell
jar for them, preserving their personality from disintegration and de-
cay under the influence of a life to which they are no longer adjusted.
Thus, we saw only the initial stages of suffering that is usually seen in
its full flower, since we were able to observe the development of the
psychopathologicalpicture by following the catamneses of our patients
from the time they were discharged from the hospital. It proved possi-
ble, by shifting the orientation of our investigationssomewhat, to make
use of the system of job training and practical job placement to conduct
a quasi-empirical analysis of the essential components of frontal le-
sions, using criteria of direct relevance to the patients’ ongoing life
situations.
The movements of our patients as they carried out the operations
their work required were correctly constructed in terms of their trajec-
tory and their relation to objects, but there was a tendency for each act
to be extreme in its intensity and perfection, i.e., for there to be a
stereotyped outcome of the initial impulse. These movements showed
no evidence of subordination to the logic of a technological process.
For example, although the movement involved in sawing, which is
objective in form, might be completely accessible to a patient, the task
of sawing something “at an angle,” i.e., of carrying out a number of
movements identical in strength and form, might cause difficulty. It
was difficult for such patients to correlate their intellectual notion of
the form of the surface with the force of the pressure to be applied: they
always sawed at maximum strength and velocity. The carpenter Ts.,
with a frontal lobe lesion, who had previously been a- skilled carpenter,
asked for a heavy instrument for his work since, when he worked with a
light one, he “could not feel” his arms and could not accurately
 RESTORATION OF WORK CAPACITY FOLLOWING BRAIN INJURIES 57

calculate the strength of the pressure. It may be assumed that to make

such a correlation it was necessary for the movement itself, in the
totality of its dynamic relationships, to be an object of the patient’s
percept ion.
Another closely related phenomenon was the patients’ lack of criti-
cal insight into their own thinking. When a person does not relate to his
own thought as a thought, conscious control of thought is impossible:
there can be no step-by-step comparison of the product of thought with
the object, so necessary for detecting and correcting mistakes. For
instance, after having finished making a shelf, a patient must think
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about where and how to attach the supports. Let us suppose that he
decides to put them in one particular place. If he relates to this act of
conceptualization as to a task he has coped with and consequently can
do properly or erroneously, he then must check his own acts in his
mind, attempting to imagine how the shelf will hang. In such a case it is
also possible to correct a mistake if one occurs. “The possibility of
being aware of a mistake is a privilege of thought as a conscious
process,” S . Ya. Rubinshtein has stated. Thus, the defect in our pa-
tients was lack of a well-defined relation to their thought as a tool for
predicting or envisioning an action, as an object of their own critical
assessment and use. These patients were unable to make a critical,
thoughtful assessment of events from the standpoint of their own inter-
ests, needs, and future destiny.
B. V. Zeigarnik links the aspontaneity of patients with frontal lobe
lesions to a disturbance in their needs. This disturbance or irregularity
may be understood in different ways. It seems to me that what takes
place is not that the strength of needs is diminished, but that there is a
defect in the way they are reflected. There are many ways in which
needs may be reflected, differing in the degree to which the subject is
cognitively aware of them; but how these needs are reflected, how and
to what extent a person is cognitively aware of his needs, and the way
they are objectified in things in the world around him determine the
person’s particular position, his relation to the situation. In our patients
this relation to the situation was profoundly inappropriate.
At the most conspicuous level, this inappropriateness was evident in
the patient’s attitude toward his disorder. The concept of “anosogno-
sia” permits a different interpretation of the indifference we observed
in our patients toward their illness. Not only was there absolutely no
‘‘internal picture” of the illness but even the patients’ self-perception
in all spheres of physical and mental activity was insufficient. All these
 58 S. YA. RUBINSHTEIN

findings warrant, I think, speaking not just of anosognosia, of a charac-

ter defect that occurs in cases of frontal lobe lesion, but also of autogno-
sia in general, an impairment of the patient’s perception of himself as
an individual person, of his own needs, of the capacities of his defects,
and of his altered perception of the world around him.
Only a very competent choice of occupations, not requiring initiative
and under the leadership and supervision of others, can help these
patients in their work. Socially speaking, the dynamics of the develop-
ment of the defects of these patients vary greatly and are very dependent
on circumstances. Just as the fate of an open wound is crucially depen-
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dent on whether the wound is sterile or has no surface infection, so the

fate of a “frontal” patient depends more than that of a normal person
on surrounding influences. If circumstances evolve favorably, the area
of most deficient behavior is limited to the personal life of the patient.
Despite an external appearance of an intact personality, when these
patients are discharged and their disability level is determined, their
lack of independence and the severity of the impairment in their work
capacity must be taken into account. However, good, intelligent guid-
ance on the part of the family is sufficient to enhance considerably the
possibility of putting the work skills of these patients to use. Systematic
and detailed guidance from another person and the organization of a
stable life routine are essentially the only factors, although powerful
ones, for compensating for disabilities and for restoring the work
capacity of this group of patients.
The work training of patients with various motor disorders was
especially interesting. Initially it seemed desirable to find easy, “spar-
ing” forms of work therapy in the ward for them. However, some pilot
work convinced us that the operations carried out in the carpenter and
joiner trades had much greater rehabilitative value, and actually were
most accessible. This is due to the fact that concordant work with both
hands is characteristic of these types of work. The close relations
between the functions of the right and the left hands, the leading and the
following hand, respectively, can vary in the same way as the relation-
ship between the functions of different joints in this system. This
concordant activity of both hands and the dynamics of the correlation
between their functions are themselves a powerful rehabilitative de-
vice. Since the normal hand cannot be in motion for a long time by
itself and a heightened, intensive, regulatory activity is required of the
normal hand, a long-acting system of gradual stimulation of the im-
paired function is created.
 RESTORATION OF WORK CAPACITY FOLLOWING BRAIN INJURIES 59

Our observations showed that even in cases in which motor activity

was severely impaired, the patients retained their previous occupational
skills and ability.
The use of special instruments and attachments designed by Profes-
sor A. V. Zaporozhets enabled us to put a large group of wounded
patients with severe forms of central paresis, ataxia, and even patients
with loss of limb to work (a detailed description and pictures of these
devices are given in a special brochure).
The development of a system of differentiated rehabilitative work
exercises and the use of special, graduated, individual devices are a
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necessary and important task. I can mention a few things based on my

experience in this area.
The performance of work operations stimulates the process of reha-
bilitation of functions. It is a good qualitative and quantitative measure
of the residual functional potential and is a way of taking the dynamics
of rehabilitation quantitatively into account. An objectively conceived,
structurally complex task involving movement and its technologically
motivated logic stimulate maximal mobilization of all the intact ele-
ments of an organ. Involving a damaged organ in the execution of an
integral work act creates for it those guiding frameworks that will
further genuine rehabilitation, or at least steer compensatory measures
in a positive direction. . . .