COMLEX OMM Final Sprint

Test-day brain dump

Autonomics

HEAD/NECK:      T1–T4     CN III, VII, IX, X
HEART:          T1–T5     X
LUNGS:          T2–T7     X
FOREGUT:        T5–T9     X
MIDGUT:         T9–T12    X
HINDGUT:        L1–L2     S2–S4
KIDNEY/URETER:  T10–L2    X/S2–S4
BLADDER:        T11–L2    S2–S4
GONADS:         T10–T11
PELVIC ORGANS:  T10–L2    S2–S4

Sacrum

• 🦴 Rule — Positive seated flexion side → dysfunctional side.
• 🦴 Rule — Forward torsion → negative spring test.
• 🚨 Trap — Backward torsion → positive spring test.
• 🦴 Rule — L5 and sacrum usually rotate opposite directions for oblique-axis torsions.
• 🎯 Setup — Name sacrum by sacral rotation on axis.
  • Example: sacral base is deep on the left, sacrum rotates left, axis is right oblique → left-on-right sacral torsion.
  • Example: sacrum rotates right on left oblique axis → right-on-left sacral torsion.
• Easy axis memory:
  • L on L/R on R = forward torsions.
  • L on R/R on L = backward torsions.
  • Same-side name/axis = forward; opposite-side name/axis = backward.

Ribs

• 🧠 Memory — BITE = Bottom Inhaled/Top Exhaled.
• 🫁 Motion — Pump handle → ribs 1–5 → AP diameter.
• 🫁 Motion — Bucket handle → ribs 6–10 → transverse diameter.
• 🫁 Motion — Caliper → ribs 11–12.
• 🎯 Setup — Inhalation dysfunction → rib stuck inhaled/elevated.
• 🎯 Setup — Exhalation dysfunction → rib stuck exhaled/depressed.
• 🚨 Key rib —
  • Inhalation group dysfunction → treat the BOTTOM rib.
  • Exhalation group dysfunction → treat the TOP rib.
• Rib muscle energy muscle map:
  • Ribs 1–2: scalenes
  • Ribs 3–5: pectoralis minor
  • Ribs 6–8/9: serratus anterior
  • Ribs 9–10/11: latissimus dorsi
  • Rib 12: quadratus lumborum

Cranial

• 🧠 Pattern — Flexion → sphenoid base superior/anterior; head widens.
• 🧠 Pattern — Extension → sphenoid base inferior/posterior; head narrows.
• 🎯 Naming — Torsion → sphenoid and occiput rotate opposite directions around AP axis.
• 🎯 Naming — Sidebending rotation → opposite around vertical axes + same around AP axes.
• 🧠 Pattern — Vertical strain → superior/inferior translation.
• 🧠 Pattern — Lateral strain → side-to-side translation.
• 🚨 Trap — Compression → restricted SBS motion; not left/right.

Counterstrain/treatment logic

• 🎯 Setup — Counterstrain → indirect + position of ease + shorten the muscle.
• 🎯 Target — Tenderpoint pain should drop by ~70% in treatment position.
• ⏱️ Timing — Hold ~90 seconds → return to neutral passively.
• ✅ Technique — Muscle energy → direct + active patient contraction.
• 🚨 Safety — HVLA → direct + passive thrust; avoid if contraindicated.

Do-not-miss OMM traps

• 🚨 Emergency — Acute abdomen/shock/neuro emergency/fracture/surgical abdomen → stabilize first, not OMT.
• 🚨 HVLA contraindications — Fracture/severe osteoporosis/instability/malignancy in area/severe neuro compromise/bleeding risk → no HVLA.
• 🚨 OA/AA trap — Do not apply thoracic/lumbar Fryette rules blindly to OA/AA.
  Why?

  OA and AA have their own cervical mechanics: OA sidebends and rotates opposite directions, while AA is essentially rotation-only for board purposes. Thoracic/lumbar Fryette rules describe neutral vs flexed/extended mechanics and can lead you to the wrong diagnosis/setup here.

• 🚨 Sacrum naming trap — Sacral torsion naming ≠ lumbar rotation/sidebending naming.
• 🚨 Chapman trap — Chapman’s points and viscerosomatics do not override next-best-step medical management.
• 🚨 Counterstrain trap — Counterstrain uses position of ease, not direct barrier.
• ✅ Priority — Lock autonomics, sacrum, ribs, counterstrain, Chapman’s, contraindications, ethics, and biostats before rare tender points.

Technique classification table

Last 24 hours only

• Brain dump: Re-draw autonomics + Chapman’s charts.
• Review final OMM miss list.
• Drill sacrum, ribs, cranial, counterstrain, and contraindications.
• Do a light ethics/biostats pass.
• Do not add heavy new content.
• Stop early enough to protect sleep.

Autonomics + viscerosomatics

Review targets

• Viscerosomatic/autonomic grid
• Savarese Chapters 1–3 for autonomics + setup rules
• Final brain-dump version of autonomics before test day

Practice tasks

• Draw the viscerosomatic/autonomic grid 3–5 times.
• Re-draw viscerosomatics + Chapman’s charts on blank paper.

Viscerosomatic/autonomic grid

Autonomic function rules

Rules/setups/traps

• 🧠 Autonomics — Vagus → splenic flexure.
• 🧠 Autonomics — Pelvic splanchnics → S2–S4.
• 🫀 Heart — T1–T5.
• 🫁 Lungs — T2–T7.
• 🍽️ Foregut — T5–T9.
• 🍽️ Midgut — T9–T12.
• 🍽️ Hindgut — L1–L2 sympathetics; S2–S4 parasympathetics.
• 🚻 GU/pelvis — T10–L2 sympathetics cluster.
• 🚨 Trap — Do not overthink autonomics if the question asks for a basic level match.

Sacrum, lumbar, pelvis

Review targets

• L5 vs sacral rules
• Sacral diagnosis setup
• Pelvic/innominate patterns

Sacral diagnosis setup

1. Seated flexion test
   • Positive side = side of sacral dysfunction.
   • If right seated flexion is positive, sacral axis is usually left oblique; if left seated flexion is positive, axis is usually right oblique.
2. Sacral sulcus
   • Deep sulcus = anterior sacral base on that side.
   • Shallow sulcus = posterior sacral base on that side.
3. Inferior lateral angle (ILA)
   • Posterior/inferior ILA helps determine sacral rotation.
4. Spring test
   • Negative spring = sacrum can spring anteriorly → usually forward torsion/flexed sacrum.
   • Positive spring = sacrum cannot spring anteriorly → usually backward torsion/extended sacrum.
5. L5 rule
   • L5 sidebends toward the sacral oblique axis.
   • L5 rotates opposite the sacrum in sacral torsions.

Sacral torsion pattern table

Bilateral sacral dysfunctions

Innominate patterns

Rules/setups/traps

• Always identify the positive seated flexion side first.
• Backward sacral torsions usually have a positive spring test.
• Forward sacral torsions usually have a negative spring test.
• L5 and sacrum usually rotate in opposite directions on oblique-axis sacral torsions.
• Example of the naming trap:
  • Lumbar diagnosis: L5 RrSl means L5 rotates right and sidebends left.
  • Sacral diagnosis: left-on-right means sacrum rotates left on a right oblique axis.
  • Do not mix the “rotation + sidebending” format with the “rotation on axis” format.
• Innominate diagnosis is about ASIS/PSIS landmarks and motion restriction, not just pain location.

Cranial

Review targets

• Cranial strain patterns
• Sphenobasilar synchondrosis motion
• Dirty Medicine cranial pattern recognition
• Visual guide for figure movement: Cranial strain patterns video

Core SBS motions

Cranial naming rules

• Torsion is named for the superior greater wing of the sphenoid.
• Sidebending rotation is named for the convexity.
• Vertical strain is named for the direction the sphenoid base moves.
• Lateral strain is named for the direction the sphenoid base moves.
• Compression is not named left/right; it is restricted SBS motion.

Practice tasks

• Practice naming cranial strain patterns from motion/landmark descriptions.
• Drill these words until automatic:
  • Flexion/extension
  • Torsion
  • Sidebending rotation
  • Vertical strain
  • Lateral strain
  • Compression
• For each practice vignette, ask:
  1. Is this rotation, sidebending-rotation, translation, or compression?
  2. What landmark is high/convex/translated?
  3. Which direction names the dysfunction?

Rules/setups/traps

• Torsion: sphenoid and occiput rotate in opposite directions around an AP axis.
• Sidebending rotation: sphenoid and occiput rotate in opposite directions around vertical axes and the same direction around AP axes.
• Vertical/lateral strains are translation patterns.
• Compression = restricted SBS motion.
• Cranial questions often reward pattern recognition more than deep mechanics.
• Trap: do not confuse torsion naming with sidebending-rotation naming.

Ribs, thoracic, cervical spine

Review targets

• Rib ME muscle associations
• Cervical + thoracic setup rules
• Rib mechanics
• Thoracic mechanics

Rib mechanics

Rib dysfunction rules

• Inhalation dysfunction = rib is stuck inhaled/elevated; it cannot exhale fully.
• Exhalation dysfunction = rib is stuck exhaled/depressed; it cannot inhale fully.
• Inhalation group dysfunction: treat the lowest rib in the group.
• Exhalation group dysfunction: treat the highest rib in the group.
• BITE mnemonic: Bottom Inhaled/Top Exhaled.

Rib muscle energy map

Thoracic/lumbar mechanics

Cervical quick rules

• Typical cervical mechanics: sidebending and rotation usually same direction.
• OA: sidebending and rotation are opposite.
• AA: rotation only; “no flex/extend, no sidebend” for board purposes.
• Do not apply thoracic/lumbar Fryette rules blindly to OA/AA.

Rules/setups/traps

• Pump-handle ribs: ribs 1–5, AP diameter.
• Bucket-handle ribs: ribs 6–10, transverse diameter.
• Caliper ribs: ribs 11–12.
• Trap: if multiple ribs are restricted, identify inhalation vs exhalation group first, then choose top/bottom key rib.
• Trap: OA/AA have special rules.

Counterstrain

Review targets

• Counterstrain positions: shorten the muscle
• Tender point setup logic
• Direct vs indirect technique classification

Core counterstrain workflow

1. Find tenderpoint.
2. Rate tenderness.
3. Place patient in position of ease until tenderness decreases by ~70%.
4. Hold about 90 seconds.
5. Passively return patient to neutral.
6. Recheck tenderpoint.

Point type distinctions

Counterstrain direction logic

• Anterior tenderpoints usually flex the region.
• Posterior tenderpoints usually extend the region.
• Add sidebending/rotation to further shorten the tender tissue.
• “F” in setups often means flexion; “E” means extension.
• Counterstrain treatment position is not the restrictive barrier.

Practice tasks

• For each tender point, ask: “What position shortens the irritated tissue?”
• Drill common counterstrain setups until the direction feels automatic.
• Pair each question stem with the treatment position rather than memorizing isolated words.

Rules/setups/traps

• 🎯 Technique — Counterstrain → indirect.
• 🎯 Position — Treatment position → position of ease.
• 🎯 Principle — Shorten the muscle/tissue.
• ⏱️ Timing — Hold position → passive return to neutral.
• 🚨 Point trap — Tenderpoints do not refer pain; trigger points do.
• 🚨 Setup trap — Counterstrain stem → do not choose a direct barrier setup.
• 🚨 Timing trap — Counterstrain ~90 sec; muscle energy 3–5 sec contraction repeated 3–5 times.

Extremities

Review targets

• Fibular head movements
• Radial head movements
• Extremity mechanics likely to appear in OMM questions

Practice tasks

• Review fibular head anterior/posterior mechanics.
• Review radial head motion with pronation/supination.
• Run focused TrueLearn questions across Extremities/Counterstrain.

Rules/setups/traps

• Radial head:
  • Pronation: radial head moves posterior.
  • Supination: radial head moves anterior.
• Fibular head:
  • Dorsiflexion tends to move fibular head anterior/superior.
  • Plantarflexion tends to move fibular head posterior/inferior.
• Trap: identify the motion restriction, then treat the restriction/barrier according to technique type.

Chapman’s points

Review targets

• Chapman’s charts
• High-yield anterior points
• GI/GU point associations
• Point-type definitions: Chapman vs trigger vs tenderpoint

Core concept

• Chapman’s points are smooth, firm nodules in deep fascia/periosteum.
• Positive Chapman reflex usually has anterior and posterior components.
• They support an organ-system association; they do not replace clinical diagnosis or emergency management.

High-yield Chapman associations

Practice tasks

• Re-draw Chapman’s charts on blank paper.
• Drill the points most likely to be confused:
  • GI points
  • GU points
  • Lung/bronchus points
  • Gallbladder/liver/pancreas points
  • Appendix vs colon points

Rules/setups/traps

• Chapman’s point = viscerosomatic nodule.
• Trigger point = referred pain.
• Tenderpoint = no referred pain and used for counterstrain.
• Appendix = tip of right rib 12.
• Colon = iliotibial bands.
• Trap: don’t let a Chapman’s point distract from emergent next-best-step management.
• Trap: do not call a tenderpoint a trigger point.

Ethics, biostats, exam-day safety

Review targets

• NBOME ethics/jurisprudence
• Ethics + biostats final pass
• OMT contraindications and safety
• Randy Neil formula recognition/2×2 table discipline

Ethics rules

OMT safety/contraindication rules

• Stabilize acute/emergent conditions before OMT.
• Avoid HVLA with fracture, severe osteoporosis, instability, malignancy in treatment area, severe neurologic compromise, or bleeding/anticoagulation risk when relevant.
• Avoid lymphatic pump when there is local rib fracture, nearby incision, traumatic disruption of spleen/liver, full stomach, or lymphatic malignancy.
• Recent spinal surgery/spinal fracture/rib fracture → avoid aggressive direct OMT.
• OMM is adjunctive after stabilization; it is not the answer to acute abdomen, shock, stroke, MI, PE, or surgical emergency.

Biostats rapid board

Randy Neil workflow

1. Read the final sentence first.
2. Identify the metric: sensitivity, specificity, PPV, NPV, ARR, NNT, RR, OR, power, CI, bias, or study design.
3. Draw the 2×2 table if any diagnostic test language appears.
4. Write the formula before plugging in numbers.
5. For long stems, ignore extra words until the requested metric is clear.

Rules/setups/traps

• 📊 Formula cue — Sensitivity/specificity → disease status known first.
• 📊 Formula cue — PPV/NPV → test result known first.
• 📊 Screening — High sensitivity → SnOUT.
• 📊 Confirmation — High specificity → SpIN.
• 📊 Prevalence — Prevalence ↑ → PPV ↑ and NPV ↓.
• 🚨 Trap — Sensitivity/specificity do not change with prevalence.
• 📊 CI rule — RR/OR confidence interval crossing 1 → not significant.
• 🚨 Trap — Tiny p-value does not guarantee clinical significance.
• 📊 Bias — Published-only positive meta-analysis/asymmetric funnel plot → publication bias.
• ✅ QI move — Choose system redesign/forcing functions over blame.

OMT safety/contraindications matrix

Emergency override rule

Technique-specific contraindications

Population-specific safety notes

• Pregnancy: avoid aggressive abdominal/pelvic force; prioritize safe positioning and obstetric evaluation for red flags.
• Pediatrics: use gentle techniques; serious illness gets medical stabilization first.
• Elderly: assume osteoporosis risk until proven otherwise; be cautious with HVLA.
• Athletes/trauma: rule out fracture/ligament instability before forceful treatment.
• Cancer patients: avoid direct force through known/suspected metastases.

Rapid recall prompts

OMM safety

Sacrum/pelvis

Ribs

Cranial

Counterstrain/Chapman’s

Ethics/biostats

Final OMM miss list framework

Use this after every TrueLearn block.

Final pass only

• Rules
• Setups
• Repeated traps
• High-yield incorrects
• Brain-dump charts
• Ethics/biostats formulas
• OMT contraindications