Fetterman’s use of captions is common in stroke recovery, neurologists say

During his first on-camera interview since suffering a stroke, Democratic Senate candidate John Fetterman stumbled over words and used closed captioning to read interview questions, prompting Republicans to raise new questions about his health.

However, disability advocates say the response shows a lack of understanding of adjustments that are often made after a major health event such as a stroke.

“I’ll sometimes hear things in a way that’s not quite clear,” Fetterman told NBC News in an interview Friday that aired Tuesday. “So I use subtitles so I can see what you’re saying on the subtitles.”

While neurological experts said they could not offer a specific diagnosis about Fetterman’s health, they noted that closed captioning is a common tool for people with auditory processing or hearing problems, conditions that have nothing to do with overall intelligence.

“This is not a question of intelligence, it’s not a question of cognition, but how we get information in and out unfortunately tends to affect how people perceive it,” said Brooke Hatfield, associate director of American Speech-Language -Hearing Association.

Fetterman’s health has become a major issue in the close race in Pennsylvania against GOP candidate Mehmet Oz. Republicans have tried to use the interview to discredit Fetterman’s cognitive abilities.

The National Republican Senatorial Committee tweeted that Fetterman will not be “transparent” about his health. Senate Republican report tweeted that NBC reported that it was difficult to speak to Fetterman without subtitles.

Problems with processing sounds can arise for several reasons. Hearing is a particularly unique sense because, unlike sight or smell, sound is processed before it even reaches the brain. There are a number of areas where understanding can be impaired even if someone has no hearing loss or intellectual disability, said Borna Bonakdarpour, associate professor of neurology at Northwestern University Feinberg School of Medicine.

Jenna Beacom, 51, a deaf media critic who lives in Columbus, Ohio, said she was surprised by how well Fetterman was able to follow the interview, even though he appeared to be relying on automatic captioning or real-time captioning. She sometimes uses this type of captioning, but said it is often riddled with errors or has significant delays.

“The purely mechanical issue of laggy captions was played in a way that made it seem like Fetterman was slow on the take, in a way that is unfair and inaccurate,” she said.

Beacom said she faces similar criticism when she is slow to respond to someone when they speak. “I have all sorts of mechanisms meant to reassure hearing people because I’m aware of this,” she said.

Fetterman suffered a stroke in May, and neuroaudiology experts said they believe him showed signs of a specific type of acquired communication disorder called aphasia, which is caused by damage to areas of the brain responsible for language. Aphasia affects about 2 million Americans, according to the National Aphasia Association, and is common after a stroke, but can also be the result of head trauma, a brain tumor or infections that damage the brain.

Importantly, aphasia does not affect intelligence, decision-making, planning or other cognitive functions of the brain, experts said. And it can be treated and improved over time through therapy.

Darlene Williamson, president of the National Aphasia Association, believe that Fetterman exhibited behavior consistent with aphasia based on his interview with NBC News. She applauded his use of closed captioning and said his use of strategies to aid communication “demonstrates his capacity.”

Aphasia can affect a person’s ability to process language either visually or auditorily, said Pélagie M. Beeson, professor of speech, language and hearing sciences at the University of Arizona.

When people have trouble choosing the right word to say or write, this is a form of expressive aphasia. Fetterman stumbled in the interview by saying the word “empathetic” when he meant “empathetic.” (He corrected himself.) Stumbling over the word could be a sign of less expressive aphasia, Beeson said.

When people have trouble processing sound from others, either translating a sound into a word, or connecting a word to its meaning, it’s called receptive aphasia. This is why people might need subtitles.

“If you say to someone with significant aphasia, ‘Can you give me the pencil?’ They say, “pencil … pencil … I should know what it is,” she said. “They heard it and put it together, but they don’t connect the meaning. It is a serious disability. He didn’t have that level of impairment.”

Beeson said Fetterman may have mild cases of both forms of aphasia, but did not see any behavior that would lead her to believe that Fetterman is struggling with the meaning of words, as he was able to respond to questions during the interview in an appropriate manner.

A person with a mild auditory processing problem will typically need more time to process sounds and may have difficulty keeping up with long sentences, fast speakers or lectures, said Sarah Lantz, a speech-language pathologist at Magee Rehabilitation Hospital, part of Jefferson Health in Philadelphia. A person with more severe auditory processing problems may have difficulty understanding a single word at a time, she said.

There are exercises people can do with speech therapists and rehabilitation specialists to help overcome auditory processing issues, Hatfield said.

When someone has auditory processing problems from a stroke, the usual pathways that language information takes have been disrupted and the signals may have to take a detour. But fortunately, there is a lot of redundancy in the brain, which means that healthy parts of the brain can support an injured part of the brain while it heals, she said.

“You still get where you need to go, but it might take you longer to get there,” Hatfield said. “The problem with speech is that people can speak really fast, so the brain has to process a lot of things at once.”

As people reinforce new connections and pathways in their brains through speech therapy and rehabilitation, they can begin to connect sound to meaning more quickly and understand people better, she said.

Others speaking to a person with auditory processing problems can help increase understanding by adding additional context when repeating themselves, slowing down when speaking, eliminating background noise, or providing the person with visual context such as captions.

In stroke recovery, people can expect to see the greatest improvement with symptoms such as auditory processing within the first year after the stroke, said Swathi Kiran, founding director of the Center for Brain Recovery at Boston University. After that, people may continue to improve, but the rate of recovery may slow. In Fetterman’s case, it’s only been about five months since his stroke, so it’s likely he’ll continue to improve at understanding speech, she said.

Sign up for the Well+Being newsletter, your source for expert advice and simple tips to help you live well every day

Leave a Comment