COMSAE PHASE 3 FORM 002 EXAMINATION QUESTIONS
AND CORRECT ANSWER WITH DETAILED
EXPLANATION GRADED A+ STUDY GUIDE FOR
OSTEOPATHIC MEDICAL STUDENT - 150 Questions
Section 1: Osteopathic Principles and Practice (Questions 1-13)
1 A patient presents with chronic low back pain and a history of recurrent urinary tract infections. On osteopathic
structural examination, you note a left-on-left sacral torsion with a deep sulcus on the left and an inferior
posterior superior iliac spine (PSIS) on the right. Which of the following best describes the Fryette mechanics
contributing to this somatic dysfunction?
A) Type I dysfunction with neutral sidebending and rotation to opposite sides
B) Type II dysfunction with non-neutral sidebending and rotation to the same side
C) Type I dysfunction with non-neutral sidebending and rotation to the same side
D) Type II dysfunction with neutral sidebending and rotation to opposite sides
Answer: B
Rationale: In sacral somatic dysfunction, a left-on-left torsion (left rotation on left oblique axis) is a Type II
(non-neutral) dysfunction, where sidebending and rotation occur to the same side. Type I dysfunctions are neutral
and have sidebending and rotation to opposite sides.
2 A patient with a history of asthma presents with restricted rib cage expansion and a tender point at the angle of
the left 5th rib. Using a direct myofascial release technique, you engage the restrictive barrier. Which of the
following best describes the tissue response you are targeting?
A) Increased tissue compliance due to activation of Golgi tendon organs
B) Release of fascial adhesions through high-velocity, low-amplitude thrust
C) Prolonged low-load stretch to induce viscoelastic deformation of fascia
D) Inhibition of muscle spindles via reciprocal innervation
Answer: C
Rationale: Myofascial release uses sustained, low-load stretch to elongate the fascia and release restrictions via
viscoelastic creep. High-velocity thrust (option B) is characteristic of HVLA, not MFR. Golgi tendon organ
activation (A) is more related to muscle energy, and reciprocal inhibition (D) is a neuromuscular reflex, not the
primary mechanism of MFR.
3 A patient presents with limited cervical rotation to the right and a tender point over the right transverse process
of C3. Using a muscle energy technique (MET) for treatment, you instruct the patient to gently push against
your resistance. Which of the following is the primary physiological mechanism being utilized?
A) Post-isometric relaxation via Golgi tendon organ activation
B) Reciprocal inhibition via spindle cell activation
C) Strain-counterstrain via passive positioning
D) High-velocity thrust to restore joint play
Answer: A
Rationale: Muscle energy technique relies on post-isometric relaxation: after a brief isometric contraction, the
muscle relaxes, allowing the practitioner to move the joint to a new barrier. This is mediated by Golgi tendon organ
inhibition of alpha motor neurons. Reciprocal inhibition (B) is a different reflex; strain-counterstrain (C) uses
,passive positioning; HVLA (D) is a direct thrust technique.
4 An osteopathic medical student is performing an osteopathic structural examination on a patient with chronic
headaches. She finds that the occipitoatlantal (OA) joint has restricted flexion and extension, with the occiput
rotated to the left. Which of the following treatment approaches would be most appropriate to address this
somatic dysfunction?
A) High-velocity, low-amplitude (HVLA) thrust to the OA joint in the direction of restriction
B) Still technique using indirect positioning and unwinding
C) Muscle energy technique using isometric contraction of the suboccipital muscles
D) Cranial osteopathic manipulation with decompression of the sphenobasilar synchondrosis
Answer: C
Rationale: For OA dysfunction with restricted motion, muscle energy technique targeting the suboccipital muscles
can effectively restore range of motion. HVLA (A) is contraindicated in the upper cervical spine without careful
consideration; Still technique (B) is indirect and may not directly address the restriction; cranial manipulation (D)
is more specific to sutural dysfunctions, not the OA joint.
5 A patient with fibromyalgia presents with diffuse pain and tenderness. You decide to use a counterstrain
technique for a tender point on the anterior chest. Which of the following best describes the correct positioning
and expected response?
A) Place the patient in a position of ease that reduces tenderness to a 0-1/10, hold for 90 seconds, then slowly
return to neutral
B) Engage the restrictive barrier and apply a high-velocity thrust
C) Have the patient perform an isometric contraction against resistance for 5 seconds
D) Apply a sustained myofascial stretch to the tender point for 2 minutes
Answer: A
Rationale: Counterstrain involves positioning the patient so that the tender point is placed into a position of ease
(reducing tenderness to near zero), held for 90 seconds, then slowly returned to neutral. This is thought to reset the
muscle spindle. Options B, C, and D describe HVLA, MET, and MFR respectively, not counterstrain.
6 A patient with a history of thoracic outlet syndrome presents with paresthesias in the right hand. On
examination, you find that the first rib is elevated and restricted in its motion. Which of the following
osteopathic manipulative techniques is most specific for treating a dysfunctional first rib?
A) HVLA thrust with the patient supine, using a thenar eminence contact on the first rib
B) Myofascial release of the pectoralis minor
C) Muscle energy technique with the patient seated, using sidebending and rotation
D) Lymphatic pump technique to enhance drainage
Answer: A
Rationale: A direct HVLA thrust to the first rib (with the patient supine and the practitioner's thenar eminence
contacting the rib) is a specific technique for first rib dysfunction. Myofascial release (B) may help but is less
specific; MET (C) can be used but is not the most specific; lymphatic pump (D) is for general lymphatic flow, not
rib dysfunction.
7 A patient with a diagnosis of irritable bowel syndrome (IBS) presents with abdominal distension and pain. On
osteopathic examination, you note visceral somatic reflexes at the T10-L2 levels. Which of the following best
explains the underlying neuroanatomical basis for these findings?
A) Somatic afferent fibers from the gut synapse in the dorsal horn and influence sympathetic efferents to the
same spinal segment
,B) Parasympathetic innervation from the vagus nerve directly modulates somatic muscle tone
C) Visceral afferent fibers converge with somatic afferents in the spinothalamic tract, leading to referred pain
D) The enteric nervous system independently causes somatic dysfunction without central involvement
Answer: A
Rationale: Viscerosomatic reflexes occur when visceral afferent input (e.g., from the gut) synapses in the spinal cord
and influences somatic efferents, leading to muscle spasm and tenderness at corresponding dermatomes. For the
midgut (IBS), this is typically T10-L2. Option C describes referred pain, but the reflex involves motor changes; B
is incorrect because vagal parasympathetics do not directly innervate somatic muscle; D underestimates central
integration.
8 During a structural examination, a patient with chronic low back pain is found to have a positive seated flexion
test on the left. Which of the following somatic dysfunctions is most consistent with this finding?
A) Right innominate rotation (anterior or posterior)
B) Left sacroiliac joint hypomobility
C) Left-on-left sacral torsion
D) Right-on-left sacral torsion
Answer: C
Rationale: The seated flexion test assesses sacral motion relative to the innominates. A positive test on the left
indicates that the left PSIS moves more superiorly than the right, suggesting that the sacrum is rotated left on a left
oblique axis (left-on-left torsion). Options A and B are less specific; D would produce a positive test on the right.
9 A patient with a history of recurrent otitis media as a child presents with a feeling of fullness in the ears and
difficulty equalizing pressure. On osteopathic examination, you find restricted motion of the temporal bones.
Which of the following cranial strain patterns is most likely contributing to eustachian tube dysfunction?
A) Sphenobasilar compression
B) Torsion of the sphenobasilar synchondrosis
C) Temporal bone internal rotation with restricted motion at the petrojugular suture
D) Frontal bone elevation
Answer: C
Rationale: The temporal bones articulate with the sphenoid and occiput; internal rotation of the temporal bone can
restrict the eustachian tube's opening, leading to dysfunction. Sphenobasilar compression (A) and torsion (B) are
more global patterns; frontal bone elevation (D) is less directly linked to eustachian tube function.
10 A patient with a diagnosis of gastroesophageal reflux disease (GERD) presents for osteopathic treatment.
Which of the following treatment approaches is most likely to address the underlying autonomic imbalance
contributing to lower esophageal sphincter (LES) tone?
A) HVLA to the thoracic spine at T5-T9
B) Myofascial release of the anterior cervical fascia
C) Osteopathic cranial manipulation to enhance vagal tone
D) Rib raising technique at the costovertebral junctions T5-T9
Answer: D
Rationale: Rib raising at T5-T9 targets the sympathetic chain (splanchnic nerves) that innervate the LES and
stomach. By normalizing sympathetic input, it may help balance autonomic tone. HVLA (A) is more direct but less
specific for autonomic effects; myofascial release (B) may help but is not primary; cranial manipulation (C) may
influence parasympathetic but is less direct for GERD.
, 11 In the context of osteopathic manipulative treatment (OMT) for a patient with chronic low back pain and
somatic dysfunction at L5-S1, which of the following best describes the rationale for using a high-velocity,
low-amplitude (HVLA) thrust technique rather than a muscle energy (ME) technique?
A) HVLA is preferred when there is a need to activate the Golgi tendon organ reflex to reduce muscle spasm.
B) HVLA is indicated when the somatic dysfunction is characterized by a restrictive barrier that is not amenable
to isometric contraction.
C) HVLA is superior for addressing viscerosomatic reflexes that perpetuate the dysfunction.
D) HVLA is chosen when the patient has a history of osteoporosis or joint instability.
Answer: B
Rationale: HVLA is used when a restrictive barrier is present and the joint is not amenable to the isometric
contraction used in ME. ME requires the patient to contract against resistance, which may be ineffective if the
barrier is too restrictive or if the patient cannot cooperate. HVLA directly overcomes the barrier with a quick,
low-amplitude thrust. Option A is incorrect because HVLA does not primarily rely on Golgi tendon organ reflexes;
that is more associated with myofascial release or strain-counterstrain. Option C is incorrect because
viscerosomatic reflexes are better addressed with indirect techniques. Option D is incorrect because HVLA is
contraindicated in osteoporosis and joint instability.
12 A patient presents with a diagnosis of acute sinusitis. The osteopathic physician identifies a tender point at the
level of C2 on the left and notes decreased motion of the sphenoid bone. Which of the following osteopathic
techniques is most appropriate to address the sphenoid dysfunction and facilitate drainage of the sinuses?
A) Balanced ligamentous tension (BLT) with a focus on the sphenobasilar symphysis.
B) Cranial vault hold with a V-spread technique to the sphenoid.
C) Rocker technique to the occipitomastoid suture.
D) Muscle energy technique to the cervical paraspinals.
Answer: B
Rationale: The V-spread technique is a cranial OMT technique used to address sphenoid dysfunction, particularly in
sinusitis, by gently separating the greater wings of the sphenoid to encourage drainage. Option A, BLT, is more
appropriate for ligamentous strain and not specific to sphenoid sinus drainage. Option C, rocker technique, is used
for occipitomastoid suture restrictions. Option D addresses cervical somatic dysfunction but does not directly
influence sphenoid motion or sinus drainage.
13 Which of the following best explains the osteopathic rationale for using a myofascial release (MFR) technique
in the treatment of a patient with chronic tension-type headaches and a palpable restriction in the suboccipital
region?
A) MFR directly inhibits nociceptive afferents by activating descending inhibitory pathways from the
periaqueductal gray.
B) MFR elongates shortened fascia and reduces strain on mechanoreceptors, thereby normalizing proprioceptive
input and reducing pain.
C) MFR works primarily by inducing a stretch reflex that resets the muscle spindle sensitivity.
D) MFR is effective because it increases blood flow to the suboccipital muscles, which is the primary mechanism
for headache relief.
Answer: B
Rationale: MFR targets fascial restrictions, which contain mechanoreceptors that influence proprioception. By
elongating the fascia, MFR reduces aberrant afferent input, normalizing muscle tone and pain perception. Option A
describes a mechanism more associated with counterirritation or acupuncture. Option C describes a mechanism
more relevant to muscle energy or HVLA. Option D is not the primary rationale; increased blood flow is a
secondary effect, not the main therapeutic goal.
AND CORRECT ANSWER WITH DETAILED
EXPLANATION GRADED A+ STUDY GUIDE FOR
OSTEOPATHIC MEDICAL STUDENT - 150 Questions
Section 1: Osteopathic Principles and Practice (Questions 1-13)
1 A patient presents with chronic low back pain and a history of recurrent urinary tract infections. On osteopathic
structural examination, you note a left-on-left sacral torsion with a deep sulcus on the left and an inferior
posterior superior iliac spine (PSIS) on the right. Which of the following best describes the Fryette mechanics
contributing to this somatic dysfunction?
A) Type I dysfunction with neutral sidebending and rotation to opposite sides
B) Type II dysfunction with non-neutral sidebending and rotation to the same side
C) Type I dysfunction with non-neutral sidebending and rotation to the same side
D) Type II dysfunction with neutral sidebending and rotation to opposite sides
Answer: B
Rationale: In sacral somatic dysfunction, a left-on-left torsion (left rotation on left oblique axis) is a Type II
(non-neutral) dysfunction, where sidebending and rotation occur to the same side. Type I dysfunctions are neutral
and have sidebending and rotation to opposite sides.
2 A patient with a history of asthma presents with restricted rib cage expansion and a tender point at the angle of
the left 5th rib. Using a direct myofascial release technique, you engage the restrictive barrier. Which of the
following best describes the tissue response you are targeting?
A) Increased tissue compliance due to activation of Golgi tendon organs
B) Release of fascial adhesions through high-velocity, low-amplitude thrust
C) Prolonged low-load stretch to induce viscoelastic deformation of fascia
D) Inhibition of muscle spindles via reciprocal innervation
Answer: C
Rationale: Myofascial release uses sustained, low-load stretch to elongate the fascia and release restrictions via
viscoelastic creep. High-velocity thrust (option B) is characteristic of HVLA, not MFR. Golgi tendon organ
activation (A) is more related to muscle energy, and reciprocal inhibition (D) is a neuromuscular reflex, not the
primary mechanism of MFR.
3 A patient presents with limited cervical rotation to the right and a tender point over the right transverse process
of C3. Using a muscle energy technique (MET) for treatment, you instruct the patient to gently push against
your resistance. Which of the following is the primary physiological mechanism being utilized?
A) Post-isometric relaxation via Golgi tendon organ activation
B) Reciprocal inhibition via spindle cell activation
C) Strain-counterstrain via passive positioning
D) High-velocity thrust to restore joint play
Answer: A
Rationale: Muscle energy technique relies on post-isometric relaxation: after a brief isometric contraction, the
muscle relaxes, allowing the practitioner to move the joint to a new barrier. This is mediated by Golgi tendon organ
inhibition of alpha motor neurons. Reciprocal inhibition (B) is a different reflex; strain-counterstrain (C) uses
,passive positioning; HVLA (D) is a direct thrust technique.
4 An osteopathic medical student is performing an osteopathic structural examination on a patient with chronic
headaches. She finds that the occipitoatlantal (OA) joint has restricted flexion and extension, with the occiput
rotated to the left. Which of the following treatment approaches would be most appropriate to address this
somatic dysfunction?
A) High-velocity, low-amplitude (HVLA) thrust to the OA joint in the direction of restriction
B) Still technique using indirect positioning and unwinding
C) Muscle energy technique using isometric contraction of the suboccipital muscles
D) Cranial osteopathic manipulation with decompression of the sphenobasilar synchondrosis
Answer: C
Rationale: For OA dysfunction with restricted motion, muscle energy technique targeting the suboccipital muscles
can effectively restore range of motion. HVLA (A) is contraindicated in the upper cervical spine without careful
consideration; Still technique (B) is indirect and may not directly address the restriction; cranial manipulation (D)
is more specific to sutural dysfunctions, not the OA joint.
5 A patient with fibromyalgia presents with diffuse pain and tenderness. You decide to use a counterstrain
technique for a tender point on the anterior chest. Which of the following best describes the correct positioning
and expected response?
A) Place the patient in a position of ease that reduces tenderness to a 0-1/10, hold for 90 seconds, then slowly
return to neutral
B) Engage the restrictive barrier and apply a high-velocity thrust
C) Have the patient perform an isometric contraction against resistance for 5 seconds
D) Apply a sustained myofascial stretch to the tender point for 2 minutes
Answer: A
Rationale: Counterstrain involves positioning the patient so that the tender point is placed into a position of ease
(reducing tenderness to near zero), held for 90 seconds, then slowly returned to neutral. This is thought to reset the
muscle spindle. Options B, C, and D describe HVLA, MET, and MFR respectively, not counterstrain.
6 A patient with a history of thoracic outlet syndrome presents with paresthesias in the right hand. On
examination, you find that the first rib is elevated and restricted in its motion. Which of the following
osteopathic manipulative techniques is most specific for treating a dysfunctional first rib?
A) HVLA thrust with the patient supine, using a thenar eminence contact on the first rib
B) Myofascial release of the pectoralis minor
C) Muscle energy technique with the patient seated, using sidebending and rotation
D) Lymphatic pump technique to enhance drainage
Answer: A
Rationale: A direct HVLA thrust to the first rib (with the patient supine and the practitioner's thenar eminence
contacting the rib) is a specific technique for first rib dysfunction. Myofascial release (B) may help but is less
specific; MET (C) can be used but is not the most specific; lymphatic pump (D) is for general lymphatic flow, not
rib dysfunction.
7 A patient with a diagnosis of irritable bowel syndrome (IBS) presents with abdominal distension and pain. On
osteopathic examination, you note visceral somatic reflexes at the T10-L2 levels. Which of the following best
explains the underlying neuroanatomical basis for these findings?
A) Somatic afferent fibers from the gut synapse in the dorsal horn and influence sympathetic efferents to the
same spinal segment
,B) Parasympathetic innervation from the vagus nerve directly modulates somatic muscle tone
C) Visceral afferent fibers converge with somatic afferents in the spinothalamic tract, leading to referred pain
D) The enteric nervous system independently causes somatic dysfunction without central involvement
Answer: A
Rationale: Viscerosomatic reflexes occur when visceral afferent input (e.g., from the gut) synapses in the spinal cord
and influences somatic efferents, leading to muscle spasm and tenderness at corresponding dermatomes. For the
midgut (IBS), this is typically T10-L2. Option C describes referred pain, but the reflex involves motor changes; B
is incorrect because vagal parasympathetics do not directly innervate somatic muscle; D underestimates central
integration.
8 During a structural examination, a patient with chronic low back pain is found to have a positive seated flexion
test on the left. Which of the following somatic dysfunctions is most consistent with this finding?
A) Right innominate rotation (anterior or posterior)
B) Left sacroiliac joint hypomobility
C) Left-on-left sacral torsion
D) Right-on-left sacral torsion
Answer: C
Rationale: The seated flexion test assesses sacral motion relative to the innominates. A positive test on the left
indicates that the left PSIS moves more superiorly than the right, suggesting that the sacrum is rotated left on a left
oblique axis (left-on-left torsion). Options A and B are less specific; D would produce a positive test on the right.
9 A patient with a history of recurrent otitis media as a child presents with a feeling of fullness in the ears and
difficulty equalizing pressure. On osteopathic examination, you find restricted motion of the temporal bones.
Which of the following cranial strain patterns is most likely contributing to eustachian tube dysfunction?
A) Sphenobasilar compression
B) Torsion of the sphenobasilar synchondrosis
C) Temporal bone internal rotation with restricted motion at the petrojugular suture
D) Frontal bone elevation
Answer: C
Rationale: The temporal bones articulate with the sphenoid and occiput; internal rotation of the temporal bone can
restrict the eustachian tube's opening, leading to dysfunction. Sphenobasilar compression (A) and torsion (B) are
more global patterns; frontal bone elevation (D) is less directly linked to eustachian tube function.
10 A patient with a diagnosis of gastroesophageal reflux disease (GERD) presents for osteopathic treatment.
Which of the following treatment approaches is most likely to address the underlying autonomic imbalance
contributing to lower esophageal sphincter (LES) tone?
A) HVLA to the thoracic spine at T5-T9
B) Myofascial release of the anterior cervical fascia
C) Osteopathic cranial manipulation to enhance vagal tone
D) Rib raising technique at the costovertebral junctions T5-T9
Answer: D
Rationale: Rib raising at T5-T9 targets the sympathetic chain (splanchnic nerves) that innervate the LES and
stomach. By normalizing sympathetic input, it may help balance autonomic tone. HVLA (A) is more direct but less
specific for autonomic effects; myofascial release (B) may help but is not primary; cranial manipulation (C) may
influence parasympathetic but is less direct for GERD.
, 11 In the context of osteopathic manipulative treatment (OMT) for a patient with chronic low back pain and
somatic dysfunction at L5-S1, which of the following best describes the rationale for using a high-velocity,
low-amplitude (HVLA) thrust technique rather than a muscle energy (ME) technique?
A) HVLA is preferred when there is a need to activate the Golgi tendon organ reflex to reduce muscle spasm.
B) HVLA is indicated when the somatic dysfunction is characterized by a restrictive barrier that is not amenable
to isometric contraction.
C) HVLA is superior for addressing viscerosomatic reflexes that perpetuate the dysfunction.
D) HVLA is chosen when the patient has a history of osteoporosis or joint instability.
Answer: B
Rationale: HVLA is used when a restrictive barrier is present and the joint is not amenable to the isometric
contraction used in ME. ME requires the patient to contract against resistance, which may be ineffective if the
barrier is too restrictive or if the patient cannot cooperate. HVLA directly overcomes the barrier with a quick,
low-amplitude thrust. Option A is incorrect because HVLA does not primarily rely on Golgi tendon organ reflexes;
that is more associated with myofascial release or strain-counterstrain. Option C is incorrect because
viscerosomatic reflexes are better addressed with indirect techniques. Option D is incorrect because HVLA is
contraindicated in osteoporosis and joint instability.
12 A patient presents with a diagnosis of acute sinusitis. The osteopathic physician identifies a tender point at the
level of C2 on the left and notes decreased motion of the sphenoid bone. Which of the following osteopathic
techniques is most appropriate to address the sphenoid dysfunction and facilitate drainage of the sinuses?
A) Balanced ligamentous tension (BLT) with a focus on the sphenobasilar symphysis.
B) Cranial vault hold with a V-spread technique to the sphenoid.
C) Rocker technique to the occipitomastoid suture.
D) Muscle energy technique to the cervical paraspinals.
Answer: B
Rationale: The V-spread technique is a cranial OMT technique used to address sphenoid dysfunction, particularly in
sinusitis, by gently separating the greater wings of the sphenoid to encourage drainage. Option A, BLT, is more
appropriate for ligamentous strain and not specific to sphenoid sinus drainage. Option C, rocker technique, is used
for occipitomastoid suture restrictions. Option D addresses cervical somatic dysfunction but does not directly
influence sphenoid motion or sinus drainage.
13 Which of the following best explains the osteopathic rationale for using a myofascial release (MFR) technique
in the treatment of a patient with chronic tension-type headaches and a palpable restriction in the suboccipital
region?
A) MFR directly inhibits nociceptive afferents by activating descending inhibitory pathways from the
periaqueductal gray.
B) MFR elongates shortened fascia and reduces strain on mechanoreceptors, thereby normalizing proprioceptive
input and reducing pain.
C) MFR works primarily by inducing a stretch reflex that resets the muscle spindle sensitivity.
D) MFR is effective because it increases blood flow to the suboccipital muscles, which is the primary mechanism
for headache relief.
Answer: B
Rationale: MFR targets fascial restrictions, which contain mechanoreceptors that influence proprioception. By
elongating the fascia, MFR reduces aberrant afferent input, normalizing muscle tone and pain perception. Option A
describes a mechanism more associated with counterirritation or acupuncture. Option C describes a mechanism
more relevant to muscle energy or HVLA. Option D is not the primary rationale; increased blood flow is a
secondary effect, not the main therapeutic goal.
