Does eccentric-exercise-induced jaw muscle soreness influence brainstem reflexes?

ObjectiveTo investigate the effects of soreness evoked by eccentric jaw exercises on two types of brainstem reflexes: the short-latency stretch reflex and the longer-latency exteroceptive suppression (ES), and to test for possible relationships between magnitude of soreness and reflex responses.MethodsThe brainstem reflexes of jaw-closing muscles were recorded before (Baseline), immediately after (Post-task), and 1 day after (1-day-after) a 30-min eccentric exercise in 15 healthy men. All subjects participated in a control session without exercise.ResultsSoreness sensations at rest and during maximum biting were significantly elevated until 1-day-after the eccentric exercise (P < 0.014). The ES responses tended to be increased (more inhibition) at Post-task and 1-day-after. There was a significant correlation between the ES response and the soreness sensation during maximum biting (P < 0.04). The jaw-stretch reflex did not show significant change after the eccentric exercise.ConclusionsMuscle soreness associated with eccentric jaw exercises has a differential impact on the jaw-stretch reflex and the ES response.SignificanceExperimentally induced acute muscle pain has previously been shown to influence both the ES and the jaw-stretch reflex, thus, different types of muscle pain and symptoms can be speculated to have different effects on a variety of brainstem reflexes.     

Effect of experimental posterior temporalis muscle pain on human brainstem reflexes.

OBJECTIVE: To study the modulation of jaw-stretch and blink reflexes by experimental posterior temporalis muscle pain. METHODS: Thirty healthy volunteers (15 males, 25.5+/-0.6 years and 15 females, 27.4 +/- 1.2 years) were included. Short-latency stretch reflex responses were evoked in the masseter and temporalis muscles by fast stretches (1 mm displacement, 10 ms ramp time) and the blink reflexes were evoked by painful electrical pulses (0.5 ms duration), delivered by a concentric electrode placed on the left lower forehead close to the supraorbital foramen before, during and 15 min after a period with experimentally induced muscle pain. RESULTS: The normalized peak-to-peak amplitude of the stretch reflex in the painful temporalis was significantly higher during pain in both males and females compared with pre- and post-pain conditions (P < 0.004). The R2 root mean square (RMS) of the blink reflex decreased significantly during muscle pain as compared to the pre-pain (P < 0.03) in both males and females. CONCLUSIONS: The present results indicated that experimental posterior temporalis muscle pain facilitates the jaw-stretch reflex, whereas the nociceptive specific blink reflex is inhibited. SIGNIFICANCE: Present study suggested that these reflexes are suitable models for probing pontine and medullary pain processing.     

Correlation and cluster analysis of sensory, pain, and reflex thresholds to various stimulus modalities in symptom-free subjects.

OBJECTIVE: In order to evaluate the possible relation between the psychophysical response and a motor reflex, sensory and pain thresholds to various stimuli were analyzed in combination with the occurrence threshold of the late masseteric exteroceptive suppression (ES2) period. METHODS: Twenty men and 20 women participated. The tactile detection threshold and the filament-prick pain detection threshold were measured on the cheek skin overlying the left masseter muscles. The pressure pain threshold and pressure pain tolerance threshold were measured at the left masseter muscle. The surface EMG was recorded from the left masseter muscle, while electrical stimuli with 13 fixed intensities were applied to the skin above the left mental nerve. The stimulation intensity at which the ES2 appeared for the first time and the lowest stimulus intensity at which the subjects reported to be painful were defined as the ES2 and pain threshold, respectively. RESULTS: There were significant positive correlations between the tactile detection threshold and the pain thresholds determined using the different stimulus modalities, and the ES2 threshold was also significantly correlated with the pain thresholds (P<0.05). Cluster analysis could significantly discriminate two distinct groups with high versus low tactile, pain and ES2 thresholds (P<0.05). CONCLUSIONS: The present findings suggested that the ES2 reflex response has a relation with the individual sensory and pain sensitivity in symptom-free subjects. SIGNIFICANCE: Combined examination of sensory, pain, and ES2 thresholds might provide complementary information on the pathophysiology underlying orofacial pain.     

Ethnic differences regarding sensory,pain, and reflex responses in the trigeminal region

ObjectiveThe present study evaluated ethnic differences in sensory, pain responses, and the exteroceptive suppression reflex (ES) in the trigeminal region.MethodsTwenty-eight Caucasian (14 men and 14 women, age from 20 to 31) and 28 gender and age matched Japanese participated. Tactile detection thresholds and filament-prick pain detection thresholds were measured on the left cheek skin. Surface EMG was recorded from the left masseter muscle, and 13 different intensities of electrical stimuli were applied to the skin overlying the left mental nerve. The first stimulation intensity at which the late ES appeared was defined as the electrical reflex threshold. The duration and suppression degree of the ES were also determined.ResultsJapanese subjects had a significantly lower sensory and pain threshold then Caucasian subjects. Caucasian subjects had a significantly lower electrical reflex threshold in comparison to Japanese subjects. Caucasian subjects had significantly longer duration of the ES and larger suppression degree of the ES compared to Japanese subjects.ConclusionsOur results demonstrate that ethnic differences exist not only concerning sensory and pain responses but also regarding reflex (motor) responses.SignificanceThe findings of this study have direct implications for studies evaluating different types of orofacial pain conditions and trigeminal reflexes.     

Brainstem reflexes and brainstem auditory evoked responses in Huntington''s chorea.

Blink reflex, corneal reflex, jaw reflex, exteroceptive suppression in masseter muscles and brainstem auditory evoked potentials were measured in 20 patients with Huntington's chorea and 12 controls. A significantly increased latency of the second component of the homolateral and heterolateral blink reflex was found in the patient group as compared with the controls. The other investigations revealed no significant differences between patients and controls except for some facilitation of the jaw reflex in the patient group. Increase of second component latency of the blink reflex in the presence of normal corneal reflexes is suggestive of functional impulse conduction disturbance in the lower brainstem. It is discussed whether in Huntington's chorea this is to be attributed to alterations of cortical or striatal influence or to local brainstem abnormalities.     

Neuropharmacological investigations in the stiff-man syndrome

Summary In a patient with the stiff-man syndrome, abnormal exteroceptive reflexes in hand and arm muscles were used as a tool for investigating the effects of various centrally acting adrenergic drugs by means of acute testing. Clonidine, tizanidine and methamphetamine induced reflex suppression whereas reserpine had a biphasic effect: transient reflex suppression and delayed reflex enhancement. The drug actions on the reflexes paralleled to some degree those on the muscle stiffness. It is concluded that alpha-adrenergic stimulation leads to reflex suppression and muscular relaxation, whereas alpha-adrenergic blockade has the opposite effect. Correspondingly, long-term oral treatment with the alpha-stimulator, tizanidine, proved successful. The hypothesis is put forward that a noradrenergic system which exerts a net inhibitory influence on muscle tone and on exteroceptive reflexes plays an important role in the pathogenesis of the stiff-man syndome.     

Effects of masticatory muscle fatigue without and with experimental pain on jaw-stretch reflexes in healthy men and women.

OBJECTIVE: To examine the effects of experimentally evoked masticatory muscle fatigue, without and with experimental muscle pain, on the short-latency jaw-stretch reflex, using a randomised crossover design. METHODS: Reflexes were evoked in both the masseter and temporalis muscles in 15 men and 13 women. The study was performed in two blocks, both containing 3 experimental conditions (before, directly after, and 15 min after provocation). Provocation consisted of a fatiguing chewing test, followed by an intramuscular injection of either isotonic saline (IS; non-painful) or hypertonic saline (HS; painful). RESULTS: No significant effects of the experimental condition 'fatigue+IS' were found for any of the reflex outcome variables. For each muscle, the 'fatigue+HS' condition yielded significantly higher normalized reflex amplitudes than the other conditions. Several muscles displayed gender differences regarding both onset latency and normalized reflex amplitude. CONCLUSIONS: Experimentally evoked mild-to-moderate muscle fatigue does not modulate the human jaw-stretch reflex. On the other hand, experimental muscle pain, evoked after the performance of a fatiguing chewing test, does yield a facilitation of this reflex. The gender differences found in both onset latency and peak-to-peak amplitude stress the need to take gender into consideration in future jaw reflex studies. SIGNIFICANCE: The sensitivity of the human jaw-stretch reflex can be modulated by HS-induced muscle pain; not by muscle fatigue that is provoked by intense chewing.     

Simultaneous modulation of the exteroceptive suppression periods in the trapezius and temporalis muscles by experimental muscle pain.

OBJECTIVE: To investigate whether the exteroceptive suppression (ES) periods in the trapezius and temporalis muscles could be simultaneously modulated by either experimental trapezius muscle pain or temporalis muscle pain. METHODS: Fourteen healthy volunteers participated in two sessions with randomised injections of either hypertonic or isotonic saline into the right trapezius muscle or right temporalis muscle. The pain intensity was continuously scored on a 10 cm electronic visual analogue scale. During muscle contraction, the early (ES1) and late (ES2) reflex in the temporalis and late (ES2) reflex in the trapezius elicited by electrical stimulation of the right infraorbital nerve were recorded pre-, during-, and post-injection. RESULTS: Hypertonic saline injection induced local muscle pain and referred pain with the maximal pain intensity of 6.3+/-0.5 cm in the right trapezius and 6.7+/-0.6 cm in the right temporalis muscles. Injection of either hypertonic or isotonic saline into the right trapezius muscle was associated with significantly shortened ES2 duration and offset time in the injected right trapezius muscle. Only injection of hypertonic saline into the right trapezius muscle could significantly reduce the ES2 offset time and decrease the degree of suppression of ES2 in the right temporalis and left trapezius muscles. Injection of either hypertonic or isotonic saline into the right trapezius muscle evoked no changes in ES2 parameters in the left temporalis muscle. Injection of hypertonic saline, but not isotonic saline, into the right temporalis muscle caused a significantly shorter ES2 offset time and shorter ES2 duration bilaterally in the temporalis and trapezius muscles. CONCLUSIONS: The findings of the present study provide evidence for a bi-directional effects reflecting convergence of muscle afferents from the trigeminal and upper cervical neural systems in humans, which may partly underlie the manifestations of pain referral between these two areas.     

Gender difference in masseteric exteroceptive suppression period and pain perception.

OBJECTIVE: Use of brain stem reflexes in the assessment of orofacial function requires insight into the influence of demographic factors such as gender. The aim of this study was to characterize possible gender differences in the relation between quantitative measures of the masseteric exteroceptive suppression (ES) reflex response and pain perception evoked by incrementally increasing electrical stimulation. METHODS: In 12 men and 12 women, the surface electromyogram was recorded from the left masseter muscle. Thirteen fixed stimulus intensities from 5 to 35 mA at 2.5 mA increments were applied to the skin above the left mental nerve. The stimulation intensity at which the late ES appeared first and the first intensity at which the subjects reported the stimulus intensity to be painful were defined as the reflex threshold (RT) and pain threshold (PT), respectively. Furthermore, data were analyzed using stimulus-response curves, and the reflex appearance levels (RAL), the saturation level, the slope from appearance to saturation of the reflex (SLP), and the pain appearance level (PAL) were determined. RESULTS: The PT was equal to or higher than the RT in 9 of the 12 men, but only in 4 of the 12 women. Further, women had significantly lower PAL, RAL, and SLP (12.7 +/- 0.8, 12.9 +/- 1.4, and 3.0 +/- 0.9 mA, respectively) compared to men (20.3 +/- 1.6 mA, 16.7 +/- 1.1 T, and 4.1 +/- 0.4, respectively) (P < 0.05). CONCLUSIONS: The present results document that women have a lower reflex threshold and pain threshold to cutaneous electrical stimulation than men. SIGNIFICANCE: These findings suggest that gender differences may exist in the sensory-motor integration of primary afferent input from the orofacial region and that these differences should be considered in the design of future reflex studies.     

Effect of low-level clenching and subsequent muscle pain on exteroceptive suppression and resting muscle activity in human jaw muscles.

OBJECTIVE: To investigate the effects of muscle fatigue induced by low-level isometric jaw-clenching and subsequent glutamate-evoked muscle pain on the exteroceptive suppression (ES) response and resting electromyographic (EMG) activities in human jaw muscles. METHODS: The resting EMG activity and the ESs were recorded before (baseline), after low-level jaw-clenching (Post1), after subsequent glutamate or isotonic saline injections into the left masseter (Post2), and 60 min after the clenching (Post3) in 23 healthy volunteers. RESULTS: The late ES (ES2) showed more inhibition at Post1 compared with baseline (P<0.05). It was less inhibited after both types of injections (Post2), and increased at Post3 again (P<0.05) with no significant difference between the glutamate and isotonic saline sessions. The resting EMG activity increased at Post1 and Post2 (P<0.05). The glutamate injection further increased the resting EMG activity in the injected muscle (P<0.01). CONCLUSIONS: Muscle fatigue influences inhibitory reflex pathways in jaw-closing muscles and subsequent acute muscle pain potentiates the local increase in the resting EMG activity of the painful muscle. SIGNIFICANCE: Muscle fatigue which can be observed in patients with oral dysfunctions may interact with nociceptive regulation and influence the clinical presentation of jaw symptoms and function.     

Habituation of exteroceptive suppression and of exteroceptive reflexes in man as influenced by voluntary contraction.

Habituation kinetics were found to vary considerably in different polysynaptic pathways of the brain stem in man. The exteroceptive reflex of the digastric muscle habituates markedly, even for stimuli repeated at 1-min intervals. The second component of the blink reflex habituates for intervals below about 8 sec, but this can largely be prevented by steady voluntary contraction of the muscle. On the other hand the exteroceptive suppressions of the masseter muscle only disclose slight habitaution of their late component ES2 and no habituation of the early component ES1. This does not appear to be affected by voluntary activation since the suppressive effects present the same pattern in relaxed masseter muscles tested by proprioceptive reflex activation. Exteroceptive reflexes and exteroceptive suppressions of similar latencies disclose genuine and important differences in their habituation kinetics.     

Relation between perceived stimulus intensity and exteroceptive reflex responses in the human masseter muscles.

OBJECTIVES: Two periods of exteroceptive suppression are elicited in human masseter muscle following perioral electrical stimulation: ES 1 and ES2. Furthermore, in the masseter EMG, two periods of apparent excitation can be distinguished from the background activity: intersuppression period (ISP) and post-suppression period (PSP). In the present study, the relationship between nociception and ES1, ISP and PSP was investigated. METHODS: The reflex responses were electrically elicited in 15 volunteers. A novel computer algorithm was used to detect and quantitate ES1, ES2, ISP and PSP. RESULTS: (a) ES1 and ES2 were more susceptible to changes in magnitude of suppression and excitation, respectively, than ISP and PSP; (b) the on-set latencies were almost unaffected; (c) both ES1 and ES2 occurred at stimulus intensities well below pain threshold; (d) magnitude of ES1 and ES2 suppression increased with increasing stimulus intensity, but supra pain threshold stimulation did not result in further suppression; and (e) no correlation was found between perceived stimulus intensity and ES1, ISP or PSP. CONCLUSIONS:The increase in ES1 and ES2 suppression seen in our study at increasing stimulus intensity is suggested to be mediated by activity in both nociceptive and non-nociceptive fibres converging onto central interneurones in the reflex circuits. We suggest that neither ISP nor PSP are reflex responses. It is unlikely that ES1, ES2, ISP and PSP evoked by electrical stimuli are directly linked to noxious activity.     

The second exteroceptive suppression is affected by psychophysiological factors

Objective

The second exteroceptive suppression (ES2) is assumed to be an indicator of central antinociceptive processing, although some conflicting data have been produced. We examined the impact of experimentally induced psychophysiological conditions on the latency and duration of the ES2. Also, the association to the subjective evaluation of the painful electrical stimulation by which the ES2 is elicited was studied.

Methods

ES2 was assessed in 46 healthy volunteers running through four experimentally induced psychophysiological conditions: stress, relaxation, depressed mood, and heterotopic pressure pain. Conditions were presented in a repeated measure design in permuted sequences. Ten stimulation-recording sequences per condition were averaged. ES2 parameters were compared to a baseline condition and correlated to subjective pain perception.

Results

ES2 duration was found to be prolonged and ES2 latency to be shortened under the impact of relaxation and depressed mood. The subjective perception of the painful electrical stimulation was affected by the experimental conditions.

Conclusion

Data lend support to the hypothesis that the repeatedly observed limited stability of ES2 parameters might be caused by the variability of individual psychophysiological states. Against expectation, subjective pain perception is not systematically correlated with ES2 parameters. Thus it can be questioned whether the ES2 is directly associated with pain processing at all.     

Hyperekplexia and stiff-man syndrome: abnormal brainstem reflexes suggest a physiological relationship

BACKGROUND AND OBJECTIVES: Hyperekplexia and the stiff-man syndrome (SMS) are both conditions with exaggerated startle suggesting abnormal brainstem function. Investigation of brainstem reflexes may provide insight into disturbed reflex excitation and inhibition underlying these movement disorders. PATIENTS AND METHODS: Using four-channel EMG, we examined four trigeminal brainstem reflexes (monosynaptic masseter, masseter inhibitory, glabella, and orbicularis oculi blink reflexes) and their spread into pericranial muscles in five patients with familial hyperekplexia (FH), two with acquired hyperekplexia (AH), 10 with SMS, and 15 healthy control subjects. RESULTS: Both FH/AH and SMS patients had abnormal propagation of brainstem reflexes into pericranial muscles. All patients with hyperekplexia showed an abnormal short-latency (15-20 ms) reflex in the trapezius muscle with a characteristic clinical appearance ("head retraction jerk") evoked by tactile or electrical stimulation of the trigeminal nerve, but normal monosynaptic masseter reflexes. Inhibitory brainstem reflexes were attenuated in some FH/AH patients. Four of 10 patients with SMS had similar short-latency reflexes in the neck muscles and frequently showed widespread enhancement of other excitatory reflexes, reflex spasms, and attenuation of inhibitory brainstem reflexes. CONCLUSION: Reflex excitation is exaggerated and inhibition is attenuated in both stiff-man syndrome and familial or acquired hyperekplexia, indicating a physiological relationship. Reflex transmission in the brainstem appears biased towards excitation which may imply dysfunction of inhibitory glycinergic or GABAergic interneurons, or both.     

Differential Effects of a Distant Noxious Stimulus on Hindlimb Nociceptive Withdrawal Reflexes in the Rat

Recent studies indicate that the nociceptive withdrawal reflexes to individual muscles are evoked by separate reflex pathways. The present study examines whether nociceptive withdrawal reflexes to different muscles are subject to differential supraspinal control in rats. A distant noxious stimulus was used to activate a bulbospinal system which selectively inhibits 'multireceptive' neurons (i.e. neurons receiving excitatory tactile and nociceptive inputs) in the dorsal horn of the spinal cord. Withdrawal reflexes, recorded with electromyographic techniques in single hindlimb muscles, were evoked by standardized noxious pinch. Thirty-seven rats, anaesthetized with halothane and nitrous oxide, were used. Whereas withdrawal reflexes to the extensor digitorum longus and brevis, tibialis anterior and biceps posterior muscles were strongly inhibited, reflexes to interossei muscles were potentiated during noxious pinch of the nose. Reflexes to peronei muscles were not significantly changed. The effects on the reflexes usually had an onset latency of <0.5 s and outlasted the conditioning stimulation by up to 2 s. The monosynaptic la reflex to the deep peroneal nerve, innervating dorsiflexors of the digits and ankle, was not significantly changed during noxious pinch of the nose. Hence, the inhibitory effects on the hindlimb withdrawal reflexes induced by the conditioning stimulation were presumably exerted on reflex interneurons. It is concluded that nociceptive withdrawal reflexes to different hindlimb muscles are differentially controlled by descending pathways activated by a distant noxious stimulus. The results support our previous conclusion that there are separate nociceptive withdrawal reflex pathways to different hindlimb muscles.     

Exteroceptive suppression after mental nerve stimulation in patients with chronic headache

In 18 normal subjects and 36 patients with chronic headache (3 cluster headache, 18 maigraine and 15 muscle contraction headache), exteroceptive suppression in the temporalis, masseter and trapezius muscles was examined. In the temporalis and masseter muscles, early and late phases (ES1 and ES2) were observed. In the present study, late response (ES2) was examined. Patients with muscle contraction headache showed an obvious decrease of exteroceptive suppression in duration and degree. Patients with common migraine showed slight reduction of exteroceptive suppression in duration and amount, when compared with normal subjects. Patients with classic migraine or cluster headache elicited almost normal exteroceptive suppression. Exteroceptive suppression in the trapezius muscle consisted of one or two suppressive phase(s). Early phase was small and unstable. In the present study, late response with latency of about 45 ms was examined. In the trapezius muscle, migraine and patients with muscle contraction headache elicited the reduction of the exteroceptive suppression in degree. There might be the failure of the inhibitory interneuron mediating the pathway of exteroceptive suppression not only in patients with muscle contraction headache, but also in patients with migraine, especially in patients with common migraine.     

Nociceptive withdrawal reflexes evoked by uniform-temperature laser heat stimulation of large skin areas in humans

Nociceptive withdrawal reflexes (NWR) were evoked by brief (200 ms) painful CO(2) laser stimulation at five intensities (1.2, 1.4, 1.6, 1.8, and 2.0 x pain threshold) applied to nine sites (2 cm(2)) separated by 1.7 cm on the dorsal side of the foot and anterior part of the lower leg of 14 healthy volunteers. The purpose of the study was to investigate the characteristics of NWRs evoked by a natural stimulation modality. The reflexes were measured as the electromyographic response from the iliopsoas (ILI), quadriceps vastus lateralis (QVL), biceps femoris (BF), tibialis anterior (TA), and soleus (SOL) muscles. Stimulus-response relationships between heat intensity and the reflex magnitude and correlation between perceived pain intensity and reflex magnitude were observed in the ILI, QVL, BF, and TA but not the SOL. No significant differences in reflex magnitude were found between the stimulation sites. NWRs were evoked more often in flexor muscles than extensor muscles, indicating a non-site-specific reflex organization. The paper presents a new method to evoke NWRs by uniform-temperature laser heat stimulation of large skin areas in humans. These heat evoked reflexes had a stimulus-response relationship.     

The trigemino-cervical reflex in patients with trigeminal neuralgia

OBJECTIVES: To investigate the central trigeminal system in idiopathic trigeminal neuralgia (TN). MATERIALS AND METHODS: Short latency responses can be recorded in sternocleidomastoid (SCM) muscles after stimulation of the trigeminal nerve (trigemino-cervical reflex). This brainstem reflex was investigated in 40 healthy subjects and in 17 patients suffering from idiopathic TN before and after therapy for 2 months with carbamazepin. RESULTS: Before therapy, six patients presented abnormalities of SCM responses on the painful side, six patients with bilateral abnormalities, and five patients with normal responses. A significant variation in the responses after therapy was found only in the patients with unilateral abnormalities: these patients and the patients with normal reflexes before therapy also had a good response to the therapy with significant pain relief. CONCLUSIONS: Our findings suggest that the trigemino-cervical reflex could be useful in the clinical assessment of TN prior to instituting non-surgical treatment. The bilateral location of the abnormalities in some patients seems to point to a centrally located dysfunction; therefore, this study supports the idea that mechanisms in the central nervous system may play an important role in the pathophysiology of trigeminal neuralgic pain.     

Electrophysiological study on jaw-opening reflex recorded from digastric muscle in Parkinson's disease and primary cranial dystonias.

We investigated digastric reflex excitability in normals and in patients with extrapyramidal disorders such as primary cranial dystonias and Parkinson's disease. Relationships between exteroceptive suppression of masseter muscle and digastric reflex were also investigated in some cases. Digastric reflex hyperexcitability was observed in dystonic patients when compared to normals and parkinsonian patients. Furthermore, some patients with cranial dystonia presented absence of exteroceptive suppression reflex in masseter muscle with enlarged digastric response. These results indicate hyperexcitability of the digastric reflex and abnormal agonist-antagonist muscle co-contraction in chewing reflexes of patients with cranial dystonias. This shows that digastric reflex is an important electrophysiological investigation to explore the physiopathological mechanisms of primary cranial dystonias.     

An exteroceptive reflex in the sternocleidomastoid muscle produced by electrical stimulation of the supraorbital nerve in normal subjects and patients with spasmodic torticollis

We examined suppression of EMG activity in the contracting sternocleidomastoid muscles, produced by electrical stimulation of the supraorbital nerve in 10 normal subjects and 9 patients with spasmodic torticollis. This exteroceptive reflex in the sternocleidomastoid muscle consisted of 2 or 3 phases: (1) an early, small, and unstable phase of facilitation, followed by (2) a period of suppression beginning 35 msec after the stimulus, lasting for 35 msec with a reduction in EMG activity to approximately 40% of the prestimulus level, and (3) a further phase of facilitation at a latency of 70 msec, with duration 35 msec and an increase in EMG activity to approximately 35% above prestimulus levels. The latency and duration of the suppressive phase of this reflex were similar to the exteroceptive suppression of EMG activity in the masseter muscle after supraorbital nerve stimulation (masseter silent period). In patients with spasmodic torticollis, the depth of this exteroceptive suppression in the sternocleidomastoid muscles was less than that observed in an age-matched cohort of normal subjects, although the latency and duration were normal. In contrast, exteroceptive suppression in the masseter muscle was normal. These findings suggest abnormal function of inhibitory interneuronal networks between the 5th cranial nerve and the motor neurons of the spinal accessory and upper cervical nerves which mediate exteroceptive suppression in the sternocleidomastoid muscle in patients with spasmodic torticollis.