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Pamanhid at Pakiramdam ng Pakpak sa Kamay at Braso

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What causes numbness, tingling or 'pins and needles' in the hand and arm — from carpal tunnel and cubital tunnel to other nerve problems — when it matters, and what helps.

Updated Aug 2026
Isang kamay na may mga puntong parang tusok-tusok sa mga dulo ng daliri.
Ang pagkadamay o pangangati ay madalas na nagpapahiwatig ng isang pinipisil o pinipisil na nerbiyos; ang pattern nito ay tumutulong sa pagtukoy sa problema. Kieran Hirpara 4.0

Ang pahinang ito ay isinalin ng makina at hindi pa nasusuri ng isang doktor. Ang bersyong Ingles ang siyang opisyal.

Ano ang nararamdaman mo

Maaaring mapansin mo ang pagkawala ng pakiramdam o pangangati sa iyong kamay at braso. Karaniwang nangyayari ito dahil may pinipisil o pinapabagabag na nerbiyo. Ang pinakakaraniwang sanhi ay ang entrapment neuropathy ng median nerve. Ibig sabihin, pinipisil ang pangunahing nerbiyo sa iyong forearms. Maaari mong maranasan ito bilang pakiramdam ng mga karayom at karayom o pagkawala ng pakiramdam.

Ang sakit ay madalas ay sumusunod sa isang pattern. Maaari itong lumala sa gabi, na nagpabangon sa iyo mula sa pagtulog. Maaari mo ring maranasan ito pagkatapos gamitin ang iyong mga kamay para sa mga gawain tulad ng pag-type o pag-angat. Mahirap na umabot sa likod ng iyong likod upang isara ang bra. Ang pagtatakip ng isang shirt ay maaaring maging awkward o masakit. Titingnan ng iyong surgeon ang mga senyales na ito upang maunawaan ang iyong kondisyon.

Minsan, lumalabas ang mga sintomas pagkatapos ng ibang operasyon. Halimbawa, maaaring umusbong ang pagkawala ng pakiramdam pagkatapos ng operasyon sa leeg (anterior cervical discectomy and fusion) o operasyon sa balikat. Kung ikaw ay nagkaroon ng operasyon sa balikat, maaaring hindi umuunlad ang iyong mga sintomas sa pamamagitan ng pahinga o gamot lamang. Sa mga kaso na ito, tumutulong ang surgical decompression sa halos 90% ng mga pasyente upang makakuha ng ginhawa.

Maaaring mas mataas ang iyong risk kung ikaw ay may nakaraan na mga isyu sa ulnar nerve. Ang ulnar nerve ay tumatakbo mula sa iyong leeg hanggang sa iyong maliit na daliri. Kung ikaw ay may mga lesion doon, lumalaki ang iyong pagkakataon na makakuha ng carpal tunnel syndrome, lalo na sa loob ng unang dalawang taon. Habang lumalaki ang pamamaga ng ulnar nerve sa siko, lumalawak ang nerbiyo mismo.

Maaaring magkaroon ka ng hirap sa mga araw-araw na manual na kasanayan. Ang mga simpleng gawain tulad ng pag-button ng isang shirt o paghawak ng tasa ay maaaring maging clumsy. Nangyayari ito dahil apektado ang iyong position sense at touch sensation. Susuriin ng iyong care team ang mga sensasyong ito upang tulungan kang muling makuha ang lakas. Ang pag-unawa sa mga sintomas na ito ay tumutulong sa iyong surgeon na pumili ng tamang landas para sa iyong paggaling.

Ano ang nangyayari talaga

Ang pagkakaroon ng pamamanhid at pangangati sa iyong kamay at braso ay karaniwang dulot ng pinipisil na nerbiyos. Tinatawag itong nerve entrapment neuropathy. Hindi ito iisang problema lamang. Sakop nito ang isang hanay ng mga kondisyon, tulad ng pronator syndrome, kung saan pinipisil ang nerbiyos sa iyong forearms. Tinitingnan ng iyong surgeon ang buong larawan upang matulungan kang gumaling.

Minsan, bumabalik ang mga sintomas pagkatapos ng paggamot. Mahirap malaman kung bumalik ang nerve compression o kung hindi ito lubos na nawala. Ginagawa nitong mahirap i-kumpara ang mga resulta sa pagitan ng iba't ibang klinika o teknika. Upang matulungan ang iyong surgeon na gumawa ng pinakamainam na desisyon, madalas kaming gumagamit ng karagdagang mga pagsusuri. Kasama rito ang electrodiagnostic studies (EDS) at ultrasound (US). Sinusuri ng mga pagsusuring ito kung gaano kagaling gumana ang nerbiyos at tinitingnan ang hugis nito.

Kapag mayroon kang mild to moderate na mga sintomas, maaaring hindi tugma ang iyong mga sign at sintomas sa mga resulta ng mga pagsusuring ito. Sa katunayan, may malaking pagkakaiba. Ang mga clinical sign ay nagpapahiwatig ng 73% na pagkakataon ng mild-to-moderate carpal tunnel syndrome. Ngunit ipinapakita ng mga pagsusuri lamang ang 51% na pagkakataon. Ginagawa ng agwat na ito ang pagiging 100% sigurado sa diagnosis batay lamang sa mga sintomas na mahirap. Kaya nga, maaaring order ng iyong surgeon ang mga karagdagang pagsusuring ito upang kumpirmahin ang problema bago magplano ng paggamot.

Mahalaga rin ang iyong history. Kung mayroon kang nakaraang mga isyu sa ulnar nerve, mas mataas ang iyong risk na makaranas ng carpal tunnel syndrome. Pinakamataas ang risk na ito sa unang dalawang taon pagkatapos ng iyong nakaraang sugat. Habang lumalala ang ulnar nerve damage, lumalaki at namamaga ang nerbiyos mismo sa siko.

Ang pamamanhid ay maaari ring mangyari pagkatapos ng mga operasyon na malayo sa iyong kamay. Halimbawa, maaari itong umusbong pagkatapos ng neck surgery (anterior cervical discectomy and fusion) o shoulder surgery. Kung hindi tumutulong ang conservative care sa nerve pain na may kinalaman sa balikat, maaaring napaka-epektibo ang surgical decompression. Nagdudulot ito ng halos 90% na paglutas ng mga sintomas sa maraming pasyente.

Ang paggaling ay higit pa sa pag-aayos lamang ng nerbiyos. Kailangan mong mag-retrain ng iyong mga pandama. Titingnan ng iyong surgeon o therapist ang iyong pakiramdam ng hawak at posisyon upang matulungan kang muling makuha ang mga manual na kasanayan. Tinitingnan din nila kung paano nito aapektuhan ang iyong pang-araw-araw na buhay at kalidad ng buhay.

Ano ang inaasahan

Maaaring pumasok at lumabas ang iyong mga sintomas, o maaari itong manatiling pareho. Ito ay nakadepende sa tiyak na nerbiyong involved at sa dahilan kung bakit ito pinipiga. Halimbawa, ang pagkakalabo ng pakiramdam sa iyong kamay ay maaaring mangyari pagkatapos ng operasyon sa leeg o operasyon sa balikat. Kung ito ay sumusunod sa operasyon sa balikat, madalas ay hindi nagiging mas mabuti ang mga sintomas na ito sa pamamagitan ng pahinga o pisikal na terapiya lamang.

Kung mayroon kang mild hanggang moderate carpal tunnel syndrome, titingnan ng iyong surgeon ang iyong mga sign at sintomas. Gayunpaman, hindi laging tumutugma ang mga sign na ito sa resulta ng mga pagsusuri. Humigit-kumulang 73% ng mga taong may mild symptoms ay tila may kondisyong ito batay sa kanilang pakiramdam. Ngunit 51% lamang ang talagang nagpapakita nito sa mga pagsusuri ng nerbiyos o ultrasound. Ang pagkakaiba na ito ay nangangahulugan na maaaring gumamit ang iyong surgeon ng karagdagang mga pagsusuri upang maging sigurado bago irekomenda ang operasyon. Kung kumpirmahin ng mga pagsusuring ito ang problema, mas malamang na makakatulong ang operasyon.

Kung mayroon kang mga isyu sa ulnar nerve sa iyong siko, maaaring magpa-swelling ang nerbiyos. Mas malaki ang nerbiyos kung mas malala ang problema. Kung mayroon kang nakaraang mga problema sa ulnar nerve, mas mataas ang iyong risk para sa carpal tunnel syndrome, lalo na sa unang dalawang taon.

Kapag kailangan ng operasyon upang i-release ang isang trapped nerve pagkatapos ng operasyon sa balikat, ang general na outlook ay maganda. Halos 90% ng mga pasyente ay nakakakita ng pagkawala ng kanilang mga sintomas nang buo. Ibig sabihin, malamang na makabalik ka sa iyong normal na araw-araw na gawain at manual na kasanayan pagkatapos mong gumaling.

Kung hindi mo itutuwid ang kondisyong ito, maaaring magpatuloy ang mga sintomas. Tumutulong ang rehabilitation upang muling makuha mo ang pakiramdam at sense ng posisyon sa iyong kamay. Ito ay mahalaga para sa paggawa ng mga fine motor tasks. Titingnan din ng iyong surgeon kung paano ito nakakaapekto sa iyong kabuuang quality of life. Ang layunin ay bawasan ang pressure sa iyong nerbiyos upang maramdaman mo ang normal na pagkahindi muli.

Reviewed by Kieran Hirpara · 13 June 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • Median nerve entrapment neuropathy encompasses a spectrum of conditions, including pronator syndrome, which requires consolidated knowledge to improve patient outcomes [1].
  • Clear definitions distinguishing recurrence from persistent compression neuropathy are necessary to enable comparison of results across different techniques and clinics [2].
  • Agreements on supplementary diagnostics and standardized outcome measurements are needed for upper extremity revision nerve compression surgery [2].
  • Diagnosis of mild-to-moderate idiopathic median neuropathy at the carpal tunnel based on signs and symptoms is discordant from diagnosis based on electrodiagnostic studies (EDS) and ultrasound (US) [3].
  • There is severe discordance between the estimated prevalence of mild-to-moderate carpal tunnel syndrome based on clinical signs and symptoms (73%) versus EDS and US (51%) [12].
  • This discordance calls into question whether clinicians can confidently diagnose patients with mild-to-moderate carpal tunnel syndrome based on clinical presentation alone [12].
  • When signs and symptoms suggest mild-to-moderate median neuropathy and surgery is being considered, additional testing such as EDS or US may increase the probability of identifying actual median neuropathy that can benefit from surgery [3].
  • Upper-extremity neuropathy can develop following nonupper extremity surgeries, particularly anterior cervical discectomy and fusion (ACDF) [4].
  • Neuropathy symptoms following shoulder surgery were often refractory to conservative management [6].
  • Surgical decompression for neuropathy following shoulder surgery led to nearly 90% symptom resolution [6].
  • Patients with a history of ulnar nerve lesions are at a significantly increased risk of developing carpal tunnel syndrome, especially within the first 2 years [7].
  • As the severity of ulnar neuropathy at the elbow increases, the cross-sectional area (CSA) of the ulnar nerve correspondingly increases at the elbow [8].
  • Assessment of position and tactile sensations is important in determining participation in manual skills during neuropathy rehabilitation [5].
  • Quality of life domains are impacted by distal radius fracture and ulnar neuropathy, with contextual factors influencing these implications [9].

Background & Causes

  • Median nerve entrapment neuropathy includes pronator syndrome [1].
  • The anconeus epitrochlearis muscle's contribution to compression neuropathy or protection of the ulnar nerve could not be discerned for the standard population [19].
  • A bifid median nerve can cause entrapment by forearm musculature [10].
  • The pectoralis minor's unique asymmetric neurologic innervation predisposes the human shoulder to neurologic and musculoskeletal imbalance, producing the Human Disharmony Loop syndrome [18].
  • Double entrapment neuropathy of the ulnar nerve at the elbow and wrist may represent double crush syndrome [13].

Symptoms & Presentation

  • There is a severe discordance between the estimated prevalence of mild-to-moderate carpal tunnel syndrome based on clinical signs and symptoms (73%) versus electrodiagnostic studies and ultrasound (51%) [12].
  • If double crush syndrome is suspected but symptoms are mild, they may respond to conservative treatment [13].
  • Assessment of position and tactile sensations is relevant for determining participation in manual skills in patients with upper extremity neuropathy [5].
  • Assessing quality of life domains provides insight into the implications of contextual factors on quality of life for patients with distal radius fracture and ulnar neuropathy [9].

Management

  • Median nerve entrapment neuropathy reviews aim to consolidate existing knowledge to improve patient outcomes [1].
  • Clear definitions of recurrence versus persistent compression neuropathy are needed to enable comparison of results from different techniques and clinics [2].
  • Agreements on supplementary diagnostics and standardized outcome measurements are required for comparing results across different techniques and clinics [2].
  • When signs and symptoms suggest mild-to-moderate median neuropathy and surgery is being considered, additional testing such as electrodiagnostic studies (EDS) or ultrasound (US) can increase the probability of identifying actual median neuropathy that can benefit from surgery [3].
  • Assessment of position and tactile sensations should not be ignored in determining participation in manual skills during neuropathy rehabilitation [5].
  • Surgical decompression led to nearly 90% symptom resolution for neuropathy following shoulder surgery [6].
  • Assessing quality of life (QoL) domains for upper extremity conditions provides insight into the implications of contextual factors on QoL [9].
  • Surgeons should bear anomalies such as bifid median nerve entrapment by forearm musculature in mind when assessing patients with symptoms of median nerve compression [10].
  • Hand abduction tracings are a quantitative outcome measure to follow recovery over time for intrinsic hand function and can be used in patients with severe ulnar neuropathy following surgical intervention [11].
  • In cases of suspected double crush syndrome, invasive treatments should be initiated preferentially at sites with greater clinical suspicion [13].
  • Decompressing the deep motor branch of the ulnar nerve caused by heterotopic ossification allowed for spontaneous nerve recovery and reinnervation of ulnar nerve-innervated intrinsic muscles [14].
  • More than 50% of patients who did not undergo carpal tunnel release at the initial surgery for perilunate injuries required a release within the follow-up period [15].
  • Anterior interosseous nerve transfer, along with cubital and ulnar tunnel release, results in sustained clinical and electrophysiological improvements in patients with severe chronic ulnar nerve compression [16].
  • Anterior interosseous nerve transfer combined with cubital and ulnar tunnel release encourages adoption as a standard treatment for severe chronic ulnar nerve compression [16].
  • Sensory interventions on motor function, activities of daily living, and spasticity of the upper limb in people with stroke are inexpensive, noninvasive, and easy to perform [17].
  • Sensory interventions can be easily implemented into conventional therapy practice in any setting [17].

Key Considerations

  • Median nerve entrapment neuropathy encompasses a spectrum of conditions, including pronator syndrome [1].
  • Agreements on supplementary diagnostics and standardized outcome measurements are required for comparing results from different techniques and clinics in upper extremity revision nerve compression surgery [2].
  • When signs and symptoms suggest mild-to-moderate median neuropathy and surgery is being considered, additional testing such as EDS or US increases the probability of identifying actual median neuropathy that can benefit from surgery [3].
  • The severe discordance between clinical prevalence estimates (73%) and EDS/US prevalence estimates (51%) calls into question whether clinicians can confidently diagnose patients with mild-to-moderate carpal tunnel syndrome [12].
  • Hand abduction tracings serve as a quantitative outcome measure to follow recovery over time for intrinsic hand function in patients with severe ulnar neuropathy following surgical intervention [11].
  • Decompression of the deep motor branch of the ulnar nerve caused by heterotopic ossification allowed for spontaneous nerve recovery and reinnervation of ulnar nerve-innervated intrinsic muscles [14].
  • More than 50% of patients with perilunate injuries who did not undergo carpal tunnel release at initial surgery required a release within the follow-up period [15].

Key Evidence

  • [L5] By reviewing the current literature within the spectrum of median nerve entrapment neuropathies, this review aimed to enhance and summarize the current understanding by consolidating the existing knowledge for improved patient outcomes. [1] (10.1016/j.xrrt.2024.10.001)
  • [L5] The authors emphasize the need for clear definitions of recurrence versus persistent compression neuropathy, agreements on supplementary diagnostics, and standardized outcome measurements to enable comparing results from different techniques and clinics. [2] (10.1177/17531934241311822)
  • [L3] When signs and symptoms suggest mild-to-moderate median neuropathy and surgery is being considered, patients and clinicians might consider additional testing, such as EDS or US, to increase the probability of actual median neuropathy that can benefit from surgery. [3] (10.1097/corr.0000000000002751)
  • [L3] Upper-extremity neuropathy can develop following nonupper extremity surgeries, particularly ACDF. [4] (10.1016/j.jhsg.2026.100972)
  • [L3] In neuropathy rehabilitation, the assessment of position and tactile sensations should not be ignored in determining participation in manual skills. [5] (10.1016/j.jht.2024.12.005)
  • [L4] Neuropathy symptoms were often refractory to conservative management, while surgical decompression led to nearly 90% symptom resolution. [6] (10.1016/j.jseint.2024.05.011)
  • [L2] Patients with a history of ulnar nerve lesions are at a significantly increased risk of developing carpal tunnel syndrome, especially within the first 2 years. [7] (10.1016/j.jhsg.2026.100970)
  • [L2] As the severity of ulnar neuropathy at the elbow increases, the CSA of the ulnar nerve correspondingly increases at the elbow. [8] (10.1016/j.jhsa.2024.12.004)
  • [L3] Assessing QoL domains for two upper extremity conditions with different contextual factors provides insight into the implications of those factors on QoL. [9] (10.1016/j.jht.2024.11.006)
  • [L5] We encourage surgeons to bear such anomalies in mind when assessing patients with symptoms of median nerve compression. [10] (10.1177/17531934251401431)
  • [L4] Hand abduction tracings are a quantitative outcome measure to follow recovery over time for intrinsic hand function and can be used in patients with severe ulnar neuropathy following surgical intervention. [11] (10.1016/j.jht.2023.09.005)
  • [L5] There is a severe discordance between the estimated prevalence of mild-to-moderate carpal tunnel syndrome based on clinical signs and symptoms (73%) versus electrodiagnostic studies and ultrasound (51%), calling into question whether clinicians can confidently diagnose patients with mild-to-moderate CTS. [12] (10.1097/corr.0000000000002822)
  • [L4] If double crush syndrome is suspected but symptoms are mild, they may respond to conservative treatment, while invasive treatments should be initiated preferentially at sites with greater clinical suspicion. [13] (10.1186/s12891-024-07574-z)
  • [L4] Decompressing the patient's deep motor branch of the ulnar nerve allowed for spontaneous nerve recovery and reinnervation of his ulnar nerve innervated intrinsic muscles. [14] (10.1016/j.jhsg.2024.02.001)
  • [L3] More than 50% of patients who did not undergo carpal tunnel release at the initial surgery required a release within the follow-up period. [15] (10.1016/j.jhsg.2023.09.003)
  • [L4] Anterior interosseous nerve transfer, along with cubital and ulnar tunnel release, results in sustained clinical and electrophysiological improvements in patients with severe chronic ulnar nerve compression, which encourages its adoption as a standard treatment for severe chronic ulnar nerve compression. [16] (10.1177/17531934251381023)
  • [L2] These interventions are inexpensive, noninvasive, and easy to perform, so can be easily implemented into conventional therapy practice in any setting. [17] (10.1016/j.jht.2024.08.051)
  • [L4] The unique asymmetric neurologic innervation to the pectoralis minor predisposes the human shoulder to neurologic and musculoskeletal imbalance, producing the Human Disharmony Loop syndrome. [18] (10.3390/jcm14051769)
  • [L3] The contribution of the anconeus epitrochlearis to compression neuropathy or protection of the ulnar nerve could not be discerned for the standard population. [19] (10.1016/j.jse.2024.09.039)

References

[1] Median nerve entrapment neuropathy: a review on the pronator syndrome. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2024.10.001

[2] Re: van der Heijden EPA, Dailiana ZH, Giele HP. State of the art review. Upper extremity revision nerve compression surgery. J Hand Surg Eur. 2024, 49: 687–97. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934241311822

[3] Diagnosis of Mild-to-moderate Idiopathic Median Neuropathy at the Carpal Tunnel Based on Signs and Symptoms is Discordant From Diagnosis Based on Electrodiagnostic Studies and Ultrasound. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002751

[4] Incidence of Median and Ulnar Neuropathy Following Nonupper Extremity Surgery. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.100972

[5] The effect of wrist position sense and tactile recognition on manual skills in patients with upper extremity neuropathy. Journal of Hand Therapy. 2025. DOI: 10.1016/j.jht.2024.12.005

[6] The incidence and decompression rates of median and ulnar neuropathies following shoulder surgery. JSES International. 2024. DOI: 10.1016/j.jseint.2024.05.011

[7] Incidence of Carpal Tunnel Syndrome After the Diagnosis of Ulnar Neuropathy. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.100970

[8] Association of Ultrasound and Electrodiagnostic Studies in Patients Evaluated for Ulnar Neuropathy. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.12.004

[9] A retrospective analysis of quality of life domains impacted by distal radius fracture and ulnar neuropathy. Journal of Hand Therapy. 2025. DOI: 10.1016/j.jht.2024.11.006

[10] Bifid median nerve entrapment by forearm musculature – a case report and systematic literature review. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251401431

[11] The hand diagram: A novel outcome measure following supercharged end-to-side anterior interosseous nerve to ulnar nerve transfer in severe compressive ulnar neuropathy. Journal of Hand Therapy. 2024. DOI: 10.1016/j.jht.2023.09.005

[12] CORR Insights®: Diagnosis of Mild-to-moderate Idiopathic Median Neuropathy at the Carpal Tunnel Based on Signs and Symptoms is Discordant From Diagnosis Based on Electrodiagnostic Studies and Ultrasound. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002822

[13] Double entrapment neuropathy of the ulnar nerve at the elbow and the wrist : double crush syndrome?. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07574-z

[14] Posttraumatic Compressive Neuropathy of the Deep Motor Branch of the Ulnar Nerve Caused by Heterotopic Ossification. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2024.02.001

[15] Predicting Acute Median Neuropathy in Perilunate Injuries. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2023.09.003

[16] Anterior interosseous nerve transfer combined with cubital and ulnar tunnel release for severe ulnar nerve compression. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251381023

[17] CRITICAL APPRAISAL PAPER: “SENSORY INTERVENTIONS ON MOTOR FUNCTION, ACTIVITIES OF DAILY LIVING, AND SPASTICITY OF THE UPPER LIMB IN PEOPLE WITH STROKE: A RANDOMIZED CLINICAL TRIAL”. Journal of Hand Therapy. 2025. DOI: 10.1016/j.jht.2024.08.051

[18] The Human Disharmony Loop: A Case Series Proposing the Unique Role of the Pectoralis Minor in a Unifying Syndrome of Chronic Pain, Neuropathy, and Weakness. Journal of Clinical Medicine. 2025. DOI: 10.3390/jcm14051769

[19] Is the anconeus epitrochlearis muscle a predictor for ulnar nerve compression?. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.09.039

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3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.