While clinical examiners rely on the incongruence between seeming tongue weakness on confrontational testing and normal eating/swallowing/speaking in a patient’s spontaneous activities, at present there is no established maneuver for eliciting functional tongue weakness. This is because tongue weakness is tested typically only in respects to lateral deviations. But other positional testing is possible. Over 83% of people can roll their tongues lengthwise, while almost 15% can trefoil curl their tongues. Testing for an incongruence between multiple tongue positions could elicit distractible weakness attributable to psychogenic overlay.

A 36 female with history of functional neurological disorder, Ehlers-Danlos Syndrome Type III, and recent traumatic vertebral dissection returns to emergency room with chief complaint of feeling she was “slipping away.” In the ED she was placed in the hallway and felt ignored, after which she began to new symptoms concerning to her for stroke, including tongue deviation. In addition to a routine neurological exam and imaging, further testing of tongue positions beyond lateral deviations was obtained.

She was without any dysarthria or dysphagia spontaneously, when prompted to protrude her tongue straight out it deviated strongly to the right and could not willfully deviate to the left, seemingly indicating right-sided hypoglossal weakness. However, when asked to roll her tongue lengthwise, she was able to not only roll her tongue, but with encouragement could curl it into a clover-leaf. MRI brain was without evidence of structural disease.

This novel distractible maneuver allowed for full and symmetric activation of tongue muscles in a complex, coordinated way, resulting in recovery of seemingly right hypoglossal weakness on confrontational testing—favoring a functional/psychogenic source of her impairments.