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COMSAE 114 EXAM – NATIONAL BOARD OF OSTEOPATHIC
MEDICAL EXAMINERS (NBOME) COMSAE – 2026/2027
EDITION] 176 ACTUAL QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) PLUS RATIONALES | COMPREHENSIVE
EXAM PREP | INSTANT DOWNLOAD PDF
SECTION ONE: OSTEOPATHIC PRINCIPLES & PRACTICE (OPP/OMM)
Question 1
A 45-year-old male presents with acute low back pain after lifting heavy boxes.
The standing flexion test shows superior movement of the right PSIS. Which
somatic dysfunction is most likely?
A. Right anterior innominate
B. Left posterior innominate
C. Right sacral torsion on a left oblique axis
D. Bilateral innominate rotation
A. Right anterior innominate
RATIONALE: A positive standing flexion test on the right suggests iliosacral
dysfunction. The superior movement of the PSIS often correlates with a right
anterior innominate, where the ASIS is positioned anteriorly and inferiorly,
creating a functional short leg. In an anterior innominate dysfunction, the ilium
rotates anteriorly on the sacrum, causing the PSIS to move superiorly and the ASIS
to move inferiorly and anteriorly. This is the most common innominate
dysfunction seen in clinical practice and is often associated with low back pain
following lifting or bending activities.
Question 2
According to Fryette's first principle (Type I mechanics), when the spine is in a
neutral position, sidebending and rotation occur:
pg. 1
,2
A. To the same side
B. To opposite sides
C. Without rotation
D. Only in the lumbar spine
B. To opposite sides
RATIONALE: Fryette's first principle states that in a neutral spine (neither
flexed nor extended), sidebending and rotation occur to opposite sides. For
example, sidebending right is accompanied by rotation left. This principle applies
to the neutral position of the spine and is fundamental to understanding somatic
dysfunction diagnosis and treatment. Type I mechanics typically involve groups of
vertebrae and are often associated with postural adaptations. In contrast,
Fryette's second principle (Type II mechanics) applies to non-neutral (flexed or
extended) positions, where sidebending and rotation occur to the same side.
Question 3
A patient has a somatic dysfunction described as "L4 extended, rotated right,
sidebent right." According to Fryette's principles, which type of mechanics does
this represent?
A. Type I (neutral) mechanics
B. Type II (non-neutral) mechanics
C. Both Type I and Type II
D. Neither Type I nor Type II
B. Type II (non-neutral) mechanics
RATIONALE: Type II mechanics dictate that in a non-neutral position (flexion
or extension), rotation and sidebending occur to the same side. The diagnosis "L4
extended, rotated right, sidebent right" (E Rr Sr) represents a Type II somatic
dysfunction because the spine is in an extended (non-neutral) position, and
rotation and sidebending occur to the same side (right). Type II dysfunctions
typically involve a single vertebral segment and are often associated with acute,
localized restrictions. The asymmetry in a Type II dysfunction worsens in the
pg. 2
,3
position of the dysfunction (extension in this case) and improves in the opposite
position (flexion).
Question 4
Which of the following cranial techniques is specifically designed to enhance the
amplitude of the cranial rhythmic impulse (CRI)?
A. Venous sinus traction
B. Bulb compression (CV4)
C. V-spread technique
D. Frontal lift
B. Bulb compression (CV4)
RATIONALE: Compression of the fourth ventricle (CV4) is explicitly utilized to
encourage fluid movement, enhance the amplitude of the CRI, and assist with
autonomic nervous system balancing. This osteopathic cranial technique involves
applying gentle compression to the occipital condyles to influence the rhythmic
motion of the cranial bones and the cerebrospinal fluid. The CV4 technique is one
of the most important and commonly used cranial techniques in OMM. Venous
sinus traction targets venous drainage, the V-spread technique addresses specific
sutural restrictions, and frontal lift addresses frontal bone restrictions; none
primarily amplify the CRI.
Question 5
A patient presents with low back pain. On examination, you note that the right L4
transverse process is more posterior than the left. The asymmetry worsens during
lumbar flexion and normalizes during lumbar extension. What is the correct
somatic dysfunction diagnosis?
A. L4 Neutral, Rotated Right, Sidebent Left
B. L4 Flexed, Rotated Left, Sidebent Left
C. L4 Extended, Rotated Right, Sidebent Right
D. L4 Extended, Rotated Left, Sidebent Left
pg. 3
, 4
C. L4 Extended, Rotated Right, Sidebent Right
RATIONALE: The asymmetry normalizes in extension, indicating an extension
(E) somatic dysfunction (Type II mechanics). Type II mechanics dictate that
rotation and sidebending occur to the same side. Because the right transverse
process is posterior, the vertebra is rotated right (Rr) and sidebent right (Sr),
giving the diagnosis E RrSr. In Type II mechanics, the dysfunction is named based
on the position of ease (the position where the asymmetry resolves). Since the
asymmetry resolves in extension, the segment is in extension, and the rotation
and sidebending are to the same side as the posterior transverse process.
Question 6
A patient presents with visceral symptoms that correlate with specific spinal
segments. According to osteopathic principles, which reflex describes the
relationship between somatic dysfunction and visceral disease?
A. Somatovisceral reflex
B. Viscerosomatic reflex
C. Viscerovisceral reflex
D. Somatosomatic reflex
B. Viscerosomatic reflex
RATIONALE: A viscerosomatic reflex describes the phenomenon where
visceral disease or dysfunction produces somatic changes, such as muscle spasm,
tenderness, or segmental dysfunction. This reflex occurs because visceral afferent
nerves and somatic afferent nerves converge on the same spinal cord segments.
When visceral pathology stimulates afferent nerves, the resulting reflex activity
can cause somatic dysfunction in the corresponding spinal segments. For
example, gallbladder disease may cause somatic dysfunction in the right upper
thoracic segments (T5-T9). Conversely, a somatovisceral reflex refers to somatic
dysfunction affecting visceral function. Understanding these reflexes is
fundamental to osteopathic diagnosis and treatment.
pg. 4
COMSAE 114 EXAM – NATIONAL BOARD OF OSTEOPATHIC
MEDICAL EXAMINERS (NBOME) COMSAE – 2026/2027
EDITION] 176 ACTUAL QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) PLUS RATIONALES | COMPREHENSIVE
EXAM PREP | INSTANT DOWNLOAD PDF
SECTION ONE: OSTEOPATHIC PRINCIPLES & PRACTICE (OPP/OMM)
Question 1
A 45-year-old male presents with acute low back pain after lifting heavy boxes.
The standing flexion test shows superior movement of the right PSIS. Which
somatic dysfunction is most likely?
A. Right anterior innominate
B. Left posterior innominate
C. Right sacral torsion on a left oblique axis
D. Bilateral innominate rotation
A. Right anterior innominate
RATIONALE: A positive standing flexion test on the right suggests iliosacral
dysfunction. The superior movement of the PSIS often correlates with a right
anterior innominate, where the ASIS is positioned anteriorly and inferiorly,
creating a functional short leg. In an anterior innominate dysfunction, the ilium
rotates anteriorly on the sacrum, causing the PSIS to move superiorly and the ASIS
to move inferiorly and anteriorly. This is the most common innominate
dysfunction seen in clinical practice and is often associated with low back pain
following lifting or bending activities.
Question 2
According to Fryette's first principle (Type I mechanics), when the spine is in a
neutral position, sidebending and rotation occur:
pg. 1
,2
A. To the same side
B. To opposite sides
C. Without rotation
D. Only in the lumbar spine
B. To opposite sides
RATIONALE: Fryette's first principle states that in a neutral spine (neither
flexed nor extended), sidebending and rotation occur to opposite sides. For
example, sidebending right is accompanied by rotation left. This principle applies
to the neutral position of the spine and is fundamental to understanding somatic
dysfunction diagnosis and treatment. Type I mechanics typically involve groups of
vertebrae and are often associated with postural adaptations. In contrast,
Fryette's second principle (Type II mechanics) applies to non-neutral (flexed or
extended) positions, where sidebending and rotation occur to the same side.
Question 3
A patient has a somatic dysfunction described as "L4 extended, rotated right,
sidebent right." According to Fryette's principles, which type of mechanics does
this represent?
A. Type I (neutral) mechanics
B. Type II (non-neutral) mechanics
C. Both Type I and Type II
D. Neither Type I nor Type II
B. Type II (non-neutral) mechanics
RATIONALE: Type II mechanics dictate that in a non-neutral position (flexion
or extension), rotation and sidebending occur to the same side. The diagnosis "L4
extended, rotated right, sidebent right" (E Rr Sr) represents a Type II somatic
dysfunction because the spine is in an extended (non-neutral) position, and
rotation and sidebending occur to the same side (right). Type II dysfunctions
typically involve a single vertebral segment and are often associated with acute,
localized restrictions. The asymmetry in a Type II dysfunction worsens in the
pg. 2
,3
position of the dysfunction (extension in this case) and improves in the opposite
position (flexion).
Question 4
Which of the following cranial techniques is specifically designed to enhance the
amplitude of the cranial rhythmic impulse (CRI)?
A. Venous sinus traction
B. Bulb compression (CV4)
C. V-spread technique
D. Frontal lift
B. Bulb compression (CV4)
RATIONALE: Compression of the fourth ventricle (CV4) is explicitly utilized to
encourage fluid movement, enhance the amplitude of the CRI, and assist with
autonomic nervous system balancing. This osteopathic cranial technique involves
applying gentle compression to the occipital condyles to influence the rhythmic
motion of the cranial bones and the cerebrospinal fluid. The CV4 technique is one
of the most important and commonly used cranial techniques in OMM. Venous
sinus traction targets venous drainage, the V-spread technique addresses specific
sutural restrictions, and frontal lift addresses frontal bone restrictions; none
primarily amplify the CRI.
Question 5
A patient presents with low back pain. On examination, you note that the right L4
transverse process is more posterior than the left. The asymmetry worsens during
lumbar flexion and normalizes during lumbar extension. What is the correct
somatic dysfunction diagnosis?
A. L4 Neutral, Rotated Right, Sidebent Left
B. L4 Flexed, Rotated Left, Sidebent Left
C. L4 Extended, Rotated Right, Sidebent Right
D. L4 Extended, Rotated Left, Sidebent Left
pg. 3
, 4
C. L4 Extended, Rotated Right, Sidebent Right
RATIONALE: The asymmetry normalizes in extension, indicating an extension
(E) somatic dysfunction (Type II mechanics). Type II mechanics dictate that
rotation and sidebending occur to the same side. Because the right transverse
process is posterior, the vertebra is rotated right (Rr) and sidebent right (Sr),
giving the diagnosis E RrSr. In Type II mechanics, the dysfunction is named based
on the position of ease (the position where the asymmetry resolves). Since the
asymmetry resolves in extension, the segment is in extension, and the rotation
and sidebending are to the same side as the posterior transverse process.
Question 6
A patient presents with visceral symptoms that correlate with specific spinal
segments. According to osteopathic principles, which reflex describes the
relationship between somatic dysfunction and visceral disease?
A. Somatovisceral reflex
B. Viscerosomatic reflex
C. Viscerovisceral reflex
D. Somatosomatic reflex
B. Viscerosomatic reflex
RATIONALE: A viscerosomatic reflex describes the phenomenon where
visceral disease or dysfunction produces somatic changes, such as muscle spasm,
tenderness, or segmental dysfunction. This reflex occurs because visceral afferent
nerves and somatic afferent nerves converge on the same spinal cord segments.
When visceral pathology stimulates afferent nerves, the resulting reflex activity
can cause somatic dysfunction in the corresponding spinal segments. For
example, gallbladder disease may cause somatic dysfunction in the right upper
thoracic segments (T5-T9). Conversely, a somatovisceral reflex refers to somatic
dysfunction affecting visceral function. Understanding these reflexes is
fundamental to osteopathic diagnosis and treatment.
pg. 4
