Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) Osteopathic Principles, Practice, and Manipulative Treatment (OPP/OMT) Syllabus

In a structural exam, how do you name a rotated vertebra using transverse process position?

The vertebra is rotated toward the side of the posterior (more prominent) transverse process—e.g., a posterior right TP indicates rotation to the right.

What landmarks define a positive standing flexion test and what does it indicate?

While palpating both PSIS during forward bending, the side whose PSIS moves farther superiorly (cephalad) is positive, indicating iliosacral (pelvic/innominate) dysfunction on that side.

What does a positive seated flexion test indicate, and why does seating matter?

The side whose PSIS rises higher during seated forward bending is positive, indicating SACROILIAC (sacral) dysfunction; sitting locks out the lower extremities/innominates so the sacrum is isolated.

Define a sacral torsion and how it is named.

A sacral torsion is rotation of the sacrum about an oblique axis. It is named by the direction of rotation and the axis—e.g., Left-on-Left (L on L) means the sacrum rotated left on the left oblique axis (a forward torsion).

Differentiate forward and backward sacral torsions by their oblique axis.

Forward torsions: rotation and axis are the SAME side (Left-on-Left, Right-on-Right). Backward torsions: rotation and axis are OPPOSITE sides (Right-on-Left, Left-on-Right).

What is the layer-by-layer (sequential) approach in palpatory diagnosis?

Palpation proceeds from superficial to deep: skin, then subcutaneous fascia, then muscle, then deeper fascia/ligament and bone—assessing texture, temperature, moisture, and tension at each layer.

What is the fundamental difference between direct and indirect osteopathic techniques?

Direct techniques engage and move tissue TOWARD/INTO the restrictive barrier; indirect techniques move tissue AWAY from the barrier, toward the position of ease (freedom).

Explain how muscle energy technique (MET) works and which barrier it engages.

MET is a DIRECT technique: the physician positions the dysfunctional segment against the restrictive barrier and the patient contracts isometrically against counterforce. Post-isometric relaxation (and reciprocal inhibition) then allows engaging a new barrier. Repeated ~3-5 times, with relaxation before re-engaging.

What is high-velocity, low-amplitude (HVLA) and its mechanism?

HVLA (thrust technique) is DIRECT: a precise, rapid, low-amplitude force is applied through the restrictive barrier, often producing an audible 'pop' (cavitation); it activates Golgi tendon organs/muscle spindles to reset segmental motion and restore range.

Describe counterstrain (strain-counterstrain) and its key parameters.

Counterstrain is an INDIRECT technique: a tender point is monitored while the patient is moved into a position of ease that reduces tenderness by ~70% (ideally 100%), held for 90 seconds (120 sec for ribs), then SLOWLY returned to neutral.

What is facilitated positional release (FPR)?

An INDIRECT technique: the region is placed in neutral to flatten the spinal curve, a facilitating force (compression or torsion) is added, and the segment is moved into its position of ease for ~3-5 seconds to release shortened tissue.

Explain the principle of myofascial release (MFR), including direct vs. indirect variants.

MFR engages the fascial system and applies continuous palpatory feedback to load tissue until release. Direct MFR loads toward the restrictive barrier; indirect MFR follows tissue ease until a release/'creep' occurs.

What is the goal and method of lymphatic pump techniques (e.g., thoracic/pedal pump)?

To enhance lymphatic and venous return and immune function via rhythmic compression. Contraindications include osteoporosis (rib), acute infection where dissemination is a concern, and fractures. Often preceded by removing thoracic inlet/diaphragm restrictions.

What is cranial osteopathy / the cranial concept based on (Sutherland's primary respiratory mechanism)?

Five components: 1) inherent motility of the brain/spinal cord, 2) fluctuation of cerebrospinal fluid, 3) mobility of intracranial/intraspinal membranes (dural reciprocal tension), 4) articular mobility of cranial bones, 5) involuntary mobility of the sacrum between the ilia.

What is balanced ligamentous tension (BLT)/ligamentous articular strain (LAS)?

A combined/indirect approach that brings the articular ligaments to a point of balanced tension (the natural fulcrum), then allows the body's inherent forces to resolve the dysfunction.

Name absolute contraindications to HVLA in a region.

Examples: fracture or dislocation, severe osteoporosis/osteopenia, bony metastasis, vertebral/joint infection, rheumatoid arthritis at the cervical spine (atlantoaxial instability), Down syndrome (AA instability), Chiari malformation, and vertebrobasilar insufficiency for cervical HVLA.

In treatment sequencing, why are deeper/proximal regions often addressed before distal ones, and acute approaches chosen for fragile patients?

Removing central/diaphragmatic and proximal restrictions improves circulation and outcomes for distal work; for elderly, acutely ill, or fragile patients, gentle indirect/fluid techniques (counterstrain, cranial, BLT) are preferred over forceful direct techniques like HVLA.

Define viscerosomatic reflex and somatovisceral reflex.

Viscerosomatic reflex: visceral (organ) afferent input produces somatic dysfunction (e.g., paraspinal tissue texture changes) in the corresponding spinal segment. Somatovisceral reflex: somatic afferent input alters visceral function.

State the sympathetic spinal levels for the heart, lungs, and upper GI tract.

Heart: T1-T5 (left predominant). Lungs/bronchi: T2-T7. Esophagus: T2-T8. Stomach: T5-T9 (greater splanchnic). Upper GI generally arises from T5-T9.

State the sympathetic spinal levels for the small intestine, kidneys/ureters, and adrenal glands.

Small intestine: T9-T11 (with foregut/midgut splanchnics). Kidneys and upper ureters: T10-T11. Adrenal medulla: T10-T11. Gonads/ovaries: T10-T11.

What is the parasympathetic innervation of the head, neck, and thoracic/upper abdominal viscera?

The vagus nerve (CN X) supplies parasympathetics to the heart, lungs, and GI tract up to the splenic flexure; cranial nerves III, VII, IX serve the head. The OA, AA, and C2 region are key vagal somatic referral areas.

What are Chapman's reflex points and how are they used?

Chapman's points are predictable anterior and posterior fascial/lymphatic tissue texture changes (small, smooth, tender nodules) associated with specific visceral dysfunction; they aid diagnosis and can be treated with rotary stimulation to influence the related organ.

What OMT approach is used for somatic dysfunction contributing to acute low back pain?

Identify and treat lumbar, sacral, and pelvic (innominate) dysfunction—commonly with counterstrain, muscle energy, FPR, or gentle MFR; HVLA may be used if no contraindications. OMT is recommended as part of multimodal care for nonspecific low back pain.

How does OMT help in acute otitis media or sinusitis?

Lymphatic/drainage techniques (e.g., Galbreath/mandibular drainage, auricular drainage, cervical and thoracic inlet release, facial effleurage) promote eustachian tube and sinus drainage and improve lymphatic flow to support resolution.

What is the rationale for OMT in pneumonia (per studies like MOPSE)?

OMT (thoracic/rib mechanics, lymphatic pump, diaphragm release) improves chest wall motion and lymphatic flow; trials have shown reduced length of stay, antibiotic duration, and respiratory failure/death in elderly inpatients when added to standard care.

How is OMT applied in pregnancy, and what should be avoided?

OMT relieves low back/pelvic pain and edema using gentle techniques (counterstrain, MET, MFR, sacral/pelvic balancing); avoid forceful HVLA and prolonged supine positioning late in pregnancy (risk of vena cava compression).

What cranial finding in newborns may benefit from OMT, and why?

Birth-related cranial molding/strain patterns (e.g., from forceps or prolonged labor) affecting suckling, plagiocephaly, or colic; gentle cranial (osteopathy in the cranial field) and balanced membranous tension are used given the infant's pliable sutures.

What is a common pediatric consideration when performing OMT for the cervical spine?

Avoid HVLA in children with ligamentous laxity conditions (e.g., Down syndrome, juvenile RA) due to atlantoaxial instability; use indirect and gentle techniques instead.

What format is standard for documenting an osteopathic encounter, and what designates that OMT was performed?

The SOAP note (Subjective, Objective, Assessment, Plan); somatic dysfunction diagnoses are coded by region (ICD-10 M99.0x), and OMT is documented by the number of body regions treated (CPT 98925-98929: 1-2, 3-4, 5-6, 7-8, 9-10 regions).

What are the ten body regions counted for OMT billing/documentation?

Head, cervical, thoracic, lumbar, sacral, pelvic, lower extremities, upper extremities, rib cage, and abdomen/viscera.

What outcome measures are used to track OMT effectiveness?

Pre/post TART findings and range of motion, validated pain scales (VAS/NRS), functional/disability indices (e.g., Oswestry, Roland-Morris), and patient-reported outcomes, documented to justify medical necessity and guide continued treatment.