Pure & Integrated Items on COMLEX Level 1: What’s the Difference?

Year after year, many students report being under-prepared for the volume and types of OMM questions they encounter on COMLEX Level 1.

Although most students get significant exposure to relevant OMM topics in the classroom and are tested on these topics throughout their OMS1 and OMS2 years, the types of OMM questions you can expect on your COMLEX are very different than those you may have previously encountered in class.

To excel on one of the most critical sections on the COMLEX and avoid exam-day surprises, it is important to understand the unique role that OMM plays on the exam, and then to practice accordingly.

When designing the COMLEX, the NBOME is very clear that OMM is not “just another category” that is tested on the exam.

In the NBOME’s published blueprint, they state that “Osteopathic principles and practices, by design, are integrated throughout all areas of the examination, as this best reflects the manner in which osteopathic principles and practices permeate osteopathic medicine.”

While not specifically published, many estimates conclude that Osteopathic principles are incorporated into 25-30 percent of the entire test.

To better understand this “integration into all areas of the exam,” we will first need to go over important NBOME definitions for the two different types of OMM questions encountered on COMLEX:

1. PURE OMM/OPP ITEMS

These questions are created specifically to test a candidate’s knowledge of various components of Osteopathic medical practice including diagnosis and management, fundamentals and principles, and treatment techniques. When you see “pure” OMM/OPP items, you’ll likely recognize these and they will look and feel like typical OMM items that you’ve had in the classroom.

2. INTEGRATED OMM/OPP ITEM

Questions that are NOT only OMM/OPP-focused, but include OMM/OPP findings in components of the question stem itself, or in the set of answer choices (which can be the correct answer choice, or a distractor) are referred to as “integrated” OMM/OPP items.

These questions are embedded throughout the exam and can pose added challenges for students on test day. Integrated OMM items contain both osteopathic-specific and osteopathic non-specific answer choices, which can increase the difficulty of the question. Students typically do not have experience with these item types and encounter these questions for the very first time when sitting for COMLEX.

Samples of both of these item types are listed below and are embedded throughout COMBANK.

THE BEST WAY TO PREPARE IS TO PRACTICE!

Now that you know what to expect, it’s time to prepare accordingly. Be proactive and get in the habit of embedding COMLEX-style OMM questions (of both types) into your daily testing routine. Don’t let test day be the first time you encounter an “Integrated” OMM item.

Furthermore, don’t leave OMM to be the very last subject you prepare for and ignore the fact that OMM concepts will be integrated into ALL sections of the exam. Be prepared for 25 percent or more of your entire COMLEX to include both types of OMM items.

Elnaz Shahabi-Abney, DO is COMBANK’s OMM Director, and she provides these suggestions to make the biggest impact on test day:

1. Studying OMM should follow the basic principles of Osteopathic Medicine in general. Know the Structure and Function and how they relate. For example, understand spinal and joint mechanics, physiologic, anatomic and pathologic ranges of motion. This will help you discern the clinically relevant findings in each question stem.
2. Have a thorough understanding of the basics of Somatic Dysfunction in the various body regions. On the exam, you should expect to be given various structural and physical exam findings that you’ll be required to incorporate when trying to deduce the diagnosis. For the most part, there are regional rules and a few outliers, so focus on becoming familiar with those as they will often be thrown in to test your knowledge.
3. Focus on gaining a thorough understanding of the various treatment modalities conceptually rather than trying to memorize 300 different treatment positions. If you conceptually understand, for example, how Muscle Energy Technique works down to the level of the Golgi Tendon Organ, and have a general idea of how it is applied to an area, it will be easy to deduce the right answer and how it may apply to a different body region come test day.

PURE OMM/OPP SAMPLE QUESTIONS

Next, let’s look at some examples of “Pure” and “Integrated” OMM Item-types. These examples come from the 2016 Edition of COMBANK.

COMBANK Level 1 includes nearly 700 OMM items on pertinent OMM topics that most accurately reflect the types of questions tested on COMLEX.

These questions are written to mirror not only traditional “Pure” OMM questions that are on the exam, but also “Integrated” OMM questions, which are harder to recognize and require advanced decision-making.

Let’s start with some Pure OMM items from the current edition of COMBANK for COMLEX Level 1. As soon as you start reading these questions, you’ll recognize them as OMM questions.

PURE OMM – EXAMPLE #1

Q: A 25-year-old female presents to your office with a one-week history of heel pain. Pain is located on the bottom inside of her foot and worse with walking. She has no significant past medical history and exercises regularly. She tells you that she runs an average of 8 miles a day. On physical exam, you note tenderness at the proximal insertion of the plantar fascia, restricted dorsiflexion and a tender point on the proximal portion of her posterior calf. How would you treat her posterior calf tender point with counterstrain?

A. Patient prone, knee flexed, plantar flex and invert the ankle, fine tune movements until tenderness is alleviated by at least 70%
B. Patient prone, knee extended, plantar flex the ankle, fine tune movements until tenderness is alleviated by at least 70%
C. Patient prone, knee flexed, plantar flex the ankle, fine tune movements until tenderness is alleviated by at least 70%
D. Patient prone, knee extended, dorsiflex the ankle, fine tune movements until tenderness is alleviated by at least 70%
E. Patient prone, knee flexed, dorsiflex the ankle, fine tune movements until tenderness is alleviated by at least 70%

Correct Answer: C

Explanation: The correct position to treat a tender point from somatic dysfunction of the gastrocnemius with counterstrain is to flex the knee and flex the ankle. This is accomplished by applying a compressive force to the calcaneous. The physician then fine-tunes movement of ankle flexion until tenderness is maximally alleviated (greater than 70%).

Answers A & B & D & E: The correct position is to flex the knee and flex the ankle.

PURE OMM – EXAMPLE #2

Q: A 20-year-old male presents to your office with a one-week history of lateral hip pain. He is on the track team and the pain is significantly limiting his ability to practice and compete. He has tenderness to palpation near the greater trochanter, especially distal to the greater trochanter along the iliotibial band and proximally, distal to the iliac crest along the tensor fasciae latae muscle. Physical exam findings are pertinent for positive Ober’s sign, normal hip range of motion and negative FABER test. You decide to treat him conservatively with osteopathic manipulative medicine, in addition to physical therapy for iliotibial band restriction and dynamic pelvic and core exercises. Given his exquisite pain, you decide to start with counterstrain technique. How would you position the patient to treat the above mentioned points?

A. Patient lying supine, hip flexed and abducted
B. Patient lying supine, hip flexed and externally rotated
C. Patient lying supine, hip flexed and internally rotated
D. Patient lying prone, hip extended and adducted
E. Patient lying prone, hip extended and abducted

Correct Answer: A

Explanation: The tensor fasciae latae and iliotibial band tender points associated with somatic dysfunction are treated with flexion and abduction of the hip. The tensor fasciae latae is treated with slightly more flexion. Fine tuning may consist of internal or external rotation. The patient may be positioned either prone or supine.

Answers B & C & D & E: The tensor fasciae latae and iliotibial band tender points associated with somatic dysfunction are treated with flexion and abduction of the hip.

Bottom Line: Tensor fasciae latae and iliotibial band tender points are both treated with flexion and abduction (f ABD).

INTEGRATED OMM/OPP SAMPLE QUESTIONS

Now, let’s move on the Integrated OMM questions. These questions might cover topics from any discipline or body system. You might be nearly all the way through the question stem or answer choices before you realize an OMM concept is included in the question.

INTEGRATED OMM – EXAMPLE #1

Q: A 79-year-old slender female presents with a gradual decrease in height over the past 15 years. She states she used to be at least 4” taller and blames years of poor posture for “making her shrink.” She denies any pain or discomfort in her back. Exam reveals a hunched posture at the cervicothoracic junction with minimal restriction of side bending and rotation. The most likely cause of her decrease in stature is

A. Benign characteristic of aging
B. Compensatory hip flexion due to posterior rotation of sacrum
C. Psoas major spasms causing chronic hip flexion
D. Spondylolisthesis
E. Vertebral compression fractures

Correct Answer: E

Explanation: The woman in this vignette is at increased risk for osteoporosis because of her gender, age, post-menopausal status, and slender body habitus. She has likely suffered one or more vertebral compression fractures over the years which have caused her vertebral column to shorten and therefore lead to an overall decrease in stature. Vertebral compression fractures in women with osteoporosis are often asymptomatic (two thirds of patients) with the only symptom being a gradual decrease in height and decrease in cervical lordosis or the change from cervical lordosis to cervical kyphosis. Otherwise, typical manifestations include acute back pain after physical activity or minor trauma. Evaluation of osteoporosis via measurement of bone mineral density is indicated in those with clinical manifestations of low bone mass: radiographic osteopenia, history of low trauma fractures, and loss of more than 1.5 inches in height. Suspicion should be high in those with risk factors for fracture, such as long-term glucocorticoid therapy, androgen deprivation therapy for prostate cancer, hypogonadism, primary hyperparathyroidism, and intestinal disorders. Surgical treatment is at the patient and doctor’s discretion. An asymptomatic patient may opt to not have surgical correction of her compressed vertebrae at no consequence. However, this patient should be taking bisphosphonates for treatment of her osteoporosis.

Answer A: Although loss of height may be common in elderly individuals, a 4” loss would indicate a profound anatomical change in the bony structure of the body that should be explored.

Answer B: A posteriorly rotated sacrum might cause compensatory flexion, but not to the extent in which you would see a 4” decrease in stature.

Answer C: Psoas major spasms are seen in psoas syndrome which can be caused by chronic flexion at the hip, like studying for hours in a seated position. It can also be caused by kidney stones and ovarian irritation. A change in overall height is not associated with psoas syndrome.

Answer D: Spondylolisthesis is the anterior displacement of a vertebrae in relation to the one below. An individual suffering from spondylolisthesis will typically experience generalized pain in the lower back, along with intermittent shocks of shooting pain beginning in the buttock traveling downward into the back of the thigh and/or lower leg.

Bottom Line: Vertebral compression fractures are a common cause of reduced stature in elderly, post-menopausal women with osteoporosis. These fractures may be asymptomatic. Significant loss of height is not from normal aging.

INTEGRATED OMM – EXAMPLE #2

A 44-year-old female presents with severe right-sided lower back and leg pain radiating to the lateral aspect of the foot. The patient has a long history of lumbar pathology with two prior laminectomies over the past year. She complains that her pain has never been so severe and describes it as sharp in quality and 10/10 in intensity. Osteopathic exam reveals L5 (ESrRr) extended, side-bent right, rotated right. Immediate neurosurgical consultation would be warranted if the patient complained of

A. Abdominal discomfort
B. Ascending paralysis
C. Breathing difficulty
D. Generalized weakness and lethargy
E. Urinary and fecal incontinence

Correct Answer: E

Explanation: Sexual dysfunction that comes on suddenly, or loss of urinary and bowel control in patients with severe lumbar back pain, should raise suspicion for caudal equine syndrome (CES), which is a neurosurgical emergency. Additional red flags are numbness, or weakness in the legs that cause stumbling or difficulty rising from a chair or decreased sensation in the areas of the body in the perineal area. As this area is what would sit in a saddle, it is referred to as saddle anesthesia. CES results from massive posterior disc herniation which requires immediate surgical decompression. Failure to recognize this could lead to irreversible paralysis if surgery is delayed too long. Atraumatic CES primarily occurs in adults as a result of surgical morbidity, spinal disc disease, metastatic cancer, or epidural abscess. A somatic dysfunction of L5 ESrRr indicates improvement of the segment in extension. People with herniated discs usually have improvement of their radicular pain when in lumbosacral spinal extension, as the herniated disc moves anteriorly away from the spinal canal and reduces the impingement of the disc on the nerve root.

Answer A: Abdominal discomfort could be a concerning for an acute abdominal complaint but would not warrant immediate neurosurgical consultation. If anything it would warrant general surgery consultation.

Answer B: Ascending paralysis would suggest acute inflammatory demyelinating polyneuropathy (AIDP). AIDP is an autoimmune process characterized by progressive bilateral, areflexic weakness and mild sensory changes. Sensory symptoms often precede motor weakness. AIDP is not treated with neurosurgical intervention.

Answer C: Myasthenic crisis presents with apnea. Although it is a medical emergency, the treatment is not surgical, rather it consists of airway management and administration of a cholinesterase inhibitor. While this patient did complain of weakness, it was localized to the legs and accompanied by intractable pain – neither of which is typical of myasthenia gravis. The bulbar muscles are affected most commonly and most severely, but most patients also develop some degree of fluctuating generalized weakness.

Answer D: Generalized weakness and lethargy represents presenting symptoms that would raise concern for meningitis or encephalitis. This diagnosis would not necessarily warrant immediate neurosurgical consultation.

Bottom Line: Bowel and bladder incontinence in patients presenting with severe lumbar back pain with radiculopathy warrants immediate neurosurgical consultation to rule out caudal equine syndrome.

BE READY FOR OMM ON COMLEX LEVEL 1 — PRACTICE!

Now that you know what to expect from COMLEX Level 1, you should take advantage and prepare with realistic practice questions. Do not make the mistake of leaving OMM out of your study plan or leaving it for last.

Don’t forget to practice with Integrated OMM questions – something you won’t get from USMLE-style practice questions and OMM class notes. To excel on the COMLEX, you are required to recognize that OMM is not “just another section” and to plan accordingly.

To reflect the structure of COMLEX Level 1 and better prepare you for the exam, we have made substantial updates to COMBANK’s OMM sections over the past 12 months. By the end of March, there will be 300 pure OMM questions and 375 Integrated OMM questions in our COMLEX Level 1 question bank – naturally, our integrated OMM questions are spread throughout all sections of our question bank.

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