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Arthroscopy ng Balikat

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Recovery after simple or diagnostic shoulder arthroscopy with no repair — an early-mobilisation fast pathway.

Updated Jun 2026
Illustrasyon ng balikat na may dalawang maliit na keyhole na pagsingil, nakikita mula sa likod.
Maagang malayang paggalaw pagkatapos ng keyhole (arthroscopic) operasyon sa balikat. Kieran Hirpara 4.0

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

Ang protocol na ito ay sumasaklaw sa rehabilitasyon pagkatapos ng simpleng o diagnostic shoulder arthroscopy kay Dr Kieran Hirpara sa Mater Private Hospital Rockhampton: keyhole surgery kung saan sinuri, ginulo, o dinagdagan ang kasukasuan (debrided), ngunit walang itinama. Dahil walang kailangang protektahan na pag-aayos, isa ito sa pinakamabilis na operasyon sa balikat para magbawi: ang layunin ay maagang paggalaw at mabilis na pagbabalik sa karaniwang buhay. Dalhin ang pahinang ito o ang PDF nito sa iyong unang bisita sa pisyoterapeuta upang manatiling koordinado ang iyong rehabilitasyon.

Ang protocol na ito ay kumikilos kapag ang arthroscopy ay walang itinama: debridement, washout, o diagnostic assessment lamang. Kung may itinama, dinecompress, o dinistabilize sa panahon ng iyong arthroscopy, sundin ang protocol para sa prosedurang iyon: halimbawa, ang rotator cuff repair protocol kung ang iyong rotator cuff ay naayos. Kung hindi ka sigurado kung ano ang ginawa, suriin ang iyong operation note o tanungin ang mga kwarto bago magpatuloy.

Kung mayroon kang anumang alalahanin tungkol sa iyong sugat pagkatapos ng operasyon, makipag-ugnayan sa mga kwarto. Madalas na makakatulong na kunan ng larawan ang sugat at ipadala ito sa pamamagitan ng email para sa pagsusuri.

Ano ang inaasahan

Pagkatapos ng arthroscopy na walang pagkumpuni, walang nasa loob ng balikat na kailangang protektahan, kaya walang mahigpit na paghihiwalay sa paggalaw; ang iyong balikat ay agad na ginagalaw at pinapahusay base sa kaginhawaan, hindi sa takdang oras. Isang sling ang ibinibigay para sa kaginhawaan lamang: karamihan sa mga tao ay gumagamit nito sa unang isang o dalawang araw at ganap na itinatapon ito sa loob ng unang linggo. Huwag magmaneho habang nakasuot ng sling.

Ang paglalakbay sa isang tingin:

  • Yugto I — Maagang paggalaw at pagtatabi — humigit-kumulang ang unang dalawang linggo
  • Yugto II — Pagbawi ng buong paggalaw at pagsisimula ng lakas — linggo 2–6
  • Yugto III — Pagbabalik sa buong aktibidad — linggo 6 pataas

Karamihan sa mga tao ay bumabalik sa trabaho na nakabatay sa desk sa loob ng ilang araw hanggang isang linggo, at bumabalik sa pagmamaneho sa loob ng isang hanggang tatlong linggo pagkatapos matanggal ang sling, tumabi ang sakit, at may kumpiyansa sa pagkontrol ng sasakyan. Ang mas mabigat na manual na trabaho at isports ay karaniwang nangangailangan ng mas matagal, karaniwang nasa pagitan ng anim at labindalawang linggo depende sa mga hinihinging gawain sa balikat. Ang balikat ay madalas na nananatiling bahagyang masakit sa loob ng ilang linggo habang ang kasukasuan ay nagtatabi; ito ay normal at umuunlad habang bumabalik ang paggalaw at lakas.

Yugto I — Maagang paggalaw at pagpapahinga (Linggo 0–2)

Ang unang dalawang linggo ay tungkol sa pagpapahinga ng balikat habang pinapanatili itong gumagalaw. Gamitin ang sling lamang kapag ito ay nakakatulong sa kaginhawaan (karaniwan ay sa unang isang o dalawang araw) at iwan itong hindi suot sa pinakamaraming oras; hindi mo kailangang matulog gamit ito. Galawin ang iyong kamay, pulso, at siko nang malaya mula sa simula, at gamitin ang braso para sa magaan na pang-araw-araw na gawain tulad ng pagkain, paghuhugas, at pag-aayos ng damit ayon sa kaginhawaan. Ang banayad na paggalaw ng balikat ay nagsisimula agad: mga ehersisyong pendulum at tulong-galaw na unti-unting nagiging aktibong paggalaw ayon sa kakayahan ng balikat. Ang yelo at simpleng gamot sa sakit ay tumutulong upang maging komportable ang mga ehersisyo. Ang iyong mga pananggalang sa sugat ay hindi tubig-tubig kundi lumalaban sa pagbabad; panatilihing tuyo kung saan mo kaya, at maaari itong tanggalin mga sampung hanggang labindalawang araw pagkatapos ng operasyon.

Para sa iyong pisyoterapeuta:

Mga Layunin

  • Pagpapahinga ng sakit at pamamaga
  • Maagang saklaw ng paggalaw na nagsisimula mula sa tulong-galaw patungo sa aktibo ayon sa kakayahang tanggapin
  • Kalayaan sa mga magaan na gawain sa pang-araw-araw na pamumuhay
  • Pagbaba ng paggamit ng sling sa loob ng unang mga araw

Pamamahala

  • Sling para sa kaginhawaan lamang: hikayatin ang pagbaba nito sa unang mga araw at pagtatapos nito sa loob ng unang isang hanggang dalawang linggo sa huli
  • Mga ehersisyong pendulum; aktibo-tulong na saklaw ng paggalaw (pulley, baston, o wand) na unti-unting nagiging aktibong saklaw ng paggalaw sa lahat ng mga patag ayon sa kakayahang tanggapin
  • Malayang paggalaw ng kamay, pulso, at siko; trabaho ng hawak ayon sa kaginhawaan
  • Pagtatakda ng scapula at trabaho sa postura
  • Banayad na isometrikong ehersisyo para sa rotator cuff at deltoid ayon sa kaginhawaan
  • Cryotherapy at analgesia upang suportahan ang programa ng ehersisyo

Mga Paalala

  • Huwag magmaneho habang nagsusuot ng sling
  • Ang paggalaw ay iniaayos ayon sa kaginhawaan: ang matalim o nananatiling sakit ay nangangahulugang pagbaba ng lakas, hindi pagsisikap na lumampas dito
  • Panatilihing tuyo ang mga pananggalang hanggang sa ito ay matanggal sa mga 10–12 araw; iulat ang sobrang pamumula o paglabas ng likido

Mga Kriteryo para sa Pag-unlad

  • Walang sling at komportable sa mga magaan na gawain sa pang-araw-araw na pamumuhay
  • Sapat na napapahinga ang sakit upang makapagtrabaho sa aktibong saklaw ng paggalaw

Yugong II — Pagpapatibay ng buong galaw at pagsisimula ng lakas (Linggo 2–6)

Habang humihina ang baluktot ng balikat, ang pokus ay lumilipat sa pagbawi ng buong galaw at pagsisimula ng pagpapalakas. Ang aktibong galaw ay ipinagpatuloy sa lahat ng direksyon patungo sa buong saklaw, at ang mga ehersisyo na may resistensya ay nagsisimula nang dahan-dahan, kung saan ang mga isometric hold ay unti-unting lumilipat sa mga ehersisyo gamit ang elastic band para sa mga kalamnan ng rotator cuff at scapula, ayon sa antas ng kaginhawaan. Karamihan sa mga tao ay bumabalik sa trabaho na nakabatay sa desk sa unang isang o dalawang linggo kung hindi pa sila bumabalik, at sa pagmamaneho kapag ang sling ay naalis na, ang sakit ay humupa na, at pakiramdam nila ay sapat na ang kanilang kakayahang kontrolin ang sasakyan sa isang emergency (karaniwan sa loob ng isang hanggang tatlong linggo pagkatapos ng operasyon). Ang mga mas magaan na libangan ay muling isinasagawa sa yugong ito ayon sa gabay ng iyong pisioterapeuta.

Para sa iyong pisioterapeuta:

Mga Layunin

  • Buong, o halos buong, aktibong saklaw ng galaw sa lahat ng mga plano
  • Simulan ang unti-unting pagpapalakas ng rotator cuff at mga scapular stabilizer
  • Bumalik sa karaniwang mga gawain sa araw-araw, trabaho, at pagmamaneho

Pamamahala

  • Ipagpatuloy ang aktibong saklaw ng galaw sa lahat ng mga plano patungo sa buong saklaw; ang karaniwang interim na mga target ay ang forward flexion na higit sa 140–160° at external rotation na higit sa 40–60°
  • Lumipat mula sa isometrics papunta sa mga ehersisyo ng rotator cuff gamit ang elastic band (internal at external rotation malapit sa neutral), at unti-unting pag-unlad ayon sa kakayahang tanggapin
  • Pagpapalakas ng scapula: mga ehersisyo ng shrugs, retraction, protraction, at depression na unti-unting lumilipat sa may resistensya
  • Mula sa mga linggo 4, magaan na isotonic strengthening gamit ang mabibigat na timbang at mas mataas na repetitions ayon sa antas ng kaginhawaan
  • Manual therapy at paghuhubog para sa anumang natitirang kislap ng kapsula, kabilang ang paghuhubog ng posterior capsule kung kinakailangan

Mga Paalala

  • Ang pagpapalakas ay nananatili sa komportableng saklaw at hindi dapat magdulot ng sakit na nananatili pagkatapos
  • Unti-unting pagbuo ng loaded rotation sa abduction (90/90 na mga posisyon): ipakilala kapag komportable na ang neutral rotation work
  • Iwasan ang mabibigat na pagbitbit at makapangyarihang mga gawain sa itaas habang bumabalik ang lakas

Mga Kriterya para sa Pag-unlad

  • Buong o halos buong aktibong saklaw ng galaw na may minimal na sakit
  • Ang paggamit ng band at pagpapalakas ng magaan na timbang ay tinatanggap nang walang pagtaas ng sintomas

Yugong III — Pagbabalik sa buong aktibidad (Linggo 6 pataas)

Ang huling yugong ay isang unti-unting pagbabalik sa mas mabigat na pagtatayo, trabahong manual, pagsasanay sa gym, at isport. Karaniwang maaaring muling simulan ang konbensyonal na pagsasanay sa bigat mula sa humigit-kumulang anim na linggo, nagsisimula nang magaan at unti-unting pagtaas, at ang mga isport na pang-ibabaw o may kontak ay karaniwang muling sisimulan sa pagitan ng anim at labingdalawang linggo, depende sa uri ng isport at sa pagganap ng balikat. Ang sukatan para sa pagtapos ng rehabilitasyon ay isang komportableng balikat na may buong galaw at tiyak na lakas; karamihan sa mga tao ay bumabalik sa lahat ng gusto nilang gawin sa humigit-kumulang tatlong buwan, at ang anumang natirang pananakit ay patuloy na aalis sa higit pa rito.

Para sa iyong pisyoterapeuta:

Mga Layunin

  • Buong saklaw ng galaw na walang sakit
  • Pagpapanumbalik ng lakas, tibay, at kumpiyansa para sa trabaho at isport
  • Unti-unting pagbabalik sa mabigat na trabahong manual, pagsasanay sa gym, at isport

Pamamahala

  • Pag-unlad patungo sa konbensyonal na pagsasanay sa resistensya mula sa humigit-kumulang linggo 6, pag-angat mula sa makinarya patungo sa malayang bigat ayon sa kakayahan sa kontrol
  • Paggamit ng eccentric at closed-chain na trabaho ayon sa kakayahang tanggapin
  • Kondisyoning na partikular sa isport, kabilang ang isang yugong programa sa paghagis o pang-ibabaw kung kinakailangan
  • Limitahan ang mabigat na pagpapalakas ng rotator cuff sa humigit-kumulang tatlong sesyon bawat linggo upang maiwasan ang tendinopathy dahil sa sobrang paggamit

Mga Paalala

  • Ang pag-unlad ay nananatiling nakabase sa sintomas: ang pananakit na lumalala sa ilalim ng bigat o nananatili pagkatapos ay nangangahulugang pagbaba ng bigat
  • Ang pagbabalik sa isport na may kontak o pang-ibabaw ay hinihintay hanggang sa mayroong buong saklaw ng galaw na walang sakit at sapat na lakas

Mga Kriteryo para magpatuloy

  • Buong saklaw ng galaw na walang sakit na may lakas na katumbas ng kabilang bahagi para sa inilaang aktibidad
  • Mga gawain na partikular sa isport o trabaho na ginagawa nang walang pagpukaw ng sintomas

Pagkatapos ng iyong protocol

Ang mga yugto sa itaas ay naangkop mula sa mga publikadong rehabilitation protocol para sa simpleng at diagnostic shoulder arthroscopy ni Dr. Jorge Chahla (Rush University Medical Center), Dr. Benedict Nwachukwu (Hospital for Special Surgery), Dr. Blake Obrock (orthopaedic sports medicine, Amarillo), at ang gabay para sa pasyente ng Royal National Orthopaedic Hospital tungkol sa diagnostic shoulder arthroscopy. Ang mga saklaw ng linggo ay karaniwan lamang at hindi tiyak, at ang iyong rehabilitation ay indibidwal na pinamumunuan ng iyong physiotherapist, na nagtatrabaho kasama ang practice, batay sa kung paano gumagaling ang iyong balikat. Ang pahinang ito ay kasabay ng pangkalahatang payo para sa paggaling ng practice: tingnan ang pamamahala ng post-operative na sakit at pag-aalaga sa sugat. Para sa operasyon mismo, tingnan ang shoulder arthroscopy. Ang ebidensya sa likod ng protocol na ito (ang rasyonal ng maagang paggalaw, ang mga surgical trial na may placebo control, at ang mga publikadong rehabilitation protocol na ginamit nito) ay buod sa seksyon ng ebidensya, na available bilang PDF mula sa itaas ng pahinang ito.

Reviewed by Dr Kieran Hirpara · 10 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

Shoulder Arthroscopy (Diagnostic / Debridement / Washout) — Post-operative Rehabilitation

Topic scope: Post-operative rehabilitation after a generic keyhole shoulder arthroscopy in which nothing was repaired — diagnostic assessment, washout (lavage), debridement of degenerate tissue, removal of loose bodies, and isolated subacromial decompression or distal clavicle excision. Specific repair or reconstruction procedures have their own protocols that take priority — rotator-cuff repair, labral/instability stabilisation (anterior-Bankart, posterior-stabilisation, Latarjet), capsular release, biceps tenodesis and AC-joint stabilisation each convert to a slower, construct-protecting pathway. This page is the default keyhole pathway used only when the operation note confirms no repair was performed.

Defining principle of the rehab here: when nothing is repaired there is no construct to protect, so the rehab is an early-motion pathway — a sling for comfort only (days, not weeks), unrestricted use below shoulder height from day one, motion progressed on comfort rather than the calendar, and strengthening as soon as range and pain allow. The single branch point is whether anything was actually repaired or stabilised; if it was, recovery converts to that procedure's protected protocol. Unlike a cuff repair or a labral repair, there is no healing tissue that early movement can disrupt, so the usual risks of early motion (re-tear, construct failure) do not apply — the main thing early motion prevents here is post-operative stiffness.

The operation and why the rehab is fast

A keyhole (arthroscopic) shoulder operation in this scope involves looking inside the joint and subacromial space through small portals and doing one or more of: confirming a diagnosis, washing out the joint, trimming (debriding) frayed labrum, degenerate cuff or inflamed bursa, removing loose bodies, or shaving bone in a subacromial decompression or distal clavicle excision. None of these creates a repair that must heal under protection. That is the central fact that separates this pathway from cuff repair, stabilisation and the other audited protocols: the tissue is either removed or simply inspected, so the post-operative soreness — not a healing construct — is what paces recovery.

Because of this, recovery is among the quickest of any shoulder operation. Most people are back to desk-based work within days to a week, out of the sling within the first week, driving within one to three weeks once the sling is off and they can control the car confidently, and back to heavier manual work and sport somewhere between six and twelve weeks depending on the demands placed on the shoulder.

Evidence by theme

1. Early motion is the goal — there is no construct to protect

The case for early movement here is largely a mechanistic one rather than one settled by a dedicated trial: with no repair to disrupt, the only thing prolonged immobilisation achieves is avoidable stiffness, discomfort and delayed return to activity. The closest high-quality evidence comes by analogy from the cuff-repair literature, where — even with a real construct to protect — randomised trials and meta-analyses show early controlled motion does not increase re-tear and tends to reduce stiffness (number-needed-to-harm for re-tear in the order of several hundred). If early motion is safe when a repair is present, it is plainly safe when there is nothing to protect. Mechanistic + analogous moderate evidence; no debridement-specific RCT.

2. The procedures themselves: a candid note on efficacy

Two landmark placebo-controlled surgical trials bear directly on the commonest reason a no-repair arthroscopy is done — subacromial pain:

  • FIMPACT (BMJ 2018) — a double-blind trial of 210 patients randomised to arthroscopic subacromial decompression, diagnostic arthroscopy (placebo surgery), or exercise therapy. At 24 months decompression gave no benefit over diagnostic arthroscopy; both surgical arms improved, but no more than each other. Strong (placebo-controlled RCT).
  • CSAW (Lancet 2018) — a three-arm placebo-controlled UK trial reaching the same conclusion: decompression was no better than investigational (diagnostic) arthroscopy, and the small edge of either over no-treatment was not clinically important. Strong (placebo-controlled RCT).

The honest reading is that for subacromial pain the surgical element adds little over diagnostic arthroscopy or structured exercise — which reinforces why, when this operation is done, the rehabilitation (early motion, restoring strength and confidence) carries much of the recovery. A longer-term single RCT (Magnussen-class, 10-year follow-up, in the corpus) did favour decompression over therapy alone, so practice remains individualised — but the placebo-controlled data are the higher tier.

3. Debridement of degenerate tissue — limited, old evidence

Arthroscopic debridement of irreparable degenerative cuff lesions (Burkhart, J Bone Joint Surg 1995, in the corpus) can relieve pain and restore functional "force-couple" mechanics in selected patients, but the evidence base is small, old and uncontrolled. Debridement and washout are best understood as symptom-directed measures, not structural repairs — which again places the weight of recovery on rehabilitation rather than on a healing construct. Weak (historical case series).

4. The phased protocol is consensus, drawn from published surgeon protocols

The phase structure below is expert/consensus, compiled from published patient-guidance protocols for general/diagnostic shoulder arthroscopy and debridement (Chahla – Rush; Nwachukwu – HSS; Obrock; Royal National Orthopaedic Hospital). There is no rehabilitation RCT defining the optimal regimen for a no-repair arthroscopy; the week ranges are typical, not trial-derived. Weak/consensus.

Phased post-op timeline (no repair performed)

Phase Window Sling ROM / use Strengthening Notes
I — Early movement & settling Week 0–2 Comfort only, days (rarely > 1–2 wk), off ASAP; no sleeping in it Free hand/wrist/elbow + light ADLs from day 1; pendulums and assisted ROM progressing to active ROM as comfort allows Scapular setting; gentle cuff/deltoid isometrics as comfort allows Settle the post-op flare. No driving while in the sling. Dressings off ~10–12 days
II — Restore movement, start strength Week 2–6 Off Progress active ROM in all planes toward full (interim targets ~140–160° flexion, 40–60° ER) Isometric → elastic-band cuff + scapular work; light isotonic from ~wk 4 Desk work + driving once sling off, pain settled, confident to control the car (typically wk 1–3)
III — Return to full activity Week 6 onward Off Maintain full, pain-free ROM Conventional resistance training from ~wk 6; eccentric/closed-chain; sport-specific conditioning. Cap heavy cuff loading at ~3×/week Heavier manual work & sport return ~6–12 wk by demand; most back to everything by ~3 months

Branch point — if anything was repaired or stabilised: recovery converts to that procedure's protected protocol (e.g. rotator-cuff repair — sling ~6 weeks, restricted ROM, deferred strengthening, ~5 months total; or the relevant stabilisation/capsular-release pathway). The operation note and the rooms confirm which pathway applies.

Key controversies / evidence quality

  1. Does the surgery help at all (for subacromial pain)? Two placebo-controlled RCTs (FIMPACT, CSAW) found decompression no better than diagnostic arthroscopy, and arthroscopy little better than exercise. This is the strongest evidence in the topic — and it argues that, where a no-repair arthroscopy is performed, good rehabilitation is doing much of the work. Strong.
  2. Debridement evidence is thin and dated. The supportive data (e.g. Burkhart 1995) are small, uncontrolled case series; debridement is symptom-directed, not curative. Weak.
  3. The rehab protocol itself is consensus, not trial-derived. No RCT defines the optimal regimen after a no-repair arthroscopy; phase timings are typical surgeon-protocol values, and recovery is individualised by the treating physiotherapist. Weak/consensus.
  4. Safety of early motion is inferred, not directly tested here. It rests on a sound mechanism (nothing to protect) reinforced by analogy to the cuff-repair early-motion trials, rather than a debridement-specific RCT. Mechanistic + analogous moderate.

The evidence base for this generic pathway is genuinely limited. The high-quality data (placebo-controlled trials) speak to whether the operation helps, not to how best to rehabilitate it; the rehabilitation guidance is consensus-level. This is stated plainly because it is the honest position.

Evidence-strength flags (summary)

  • STRONG (placebo-controlled RCT): subacromial decompression gives no benefit over diagnostic arthroscopy — FIMPACT (BMJ 2018), CSAW (Lancet 2018).
  • MODERATE (analogous RCT/MA): safety of early controlled motion (extrapolated from cuff-repair early-motion trials — early motion does not raise re-tear and reduces stiffness even when a construct is present).
  • WEAK (historical case series): arthroscopic debridement of irreparable degenerative cuff lesions (Burkhart 1995).
  • WEAK / CONSENSUS: the post-operative rehabilitation protocol itself (published surgeon patient-guidance documents; no defining rehab RCT).
  • SAFETY NOTE (rare complication): glenohumeral chondrolysis has been linked to post-arthroscopic intra-articular continuous bupivacaine infusion and to thermal capsulorrhaphy — a reason such adjuncts are avoided, not a reflection on standard debridement.

CITATIONS

RAG corpus (180,000+ Orthopaedic articles)

  • Burkhart SS. Débridement of degenerative, irreparable lesions of the rotator cuff. J Bone Joint Surg Am. 1995. DOI: 10.2106/00004623-199506000-00006
  • Magnussen R, et al. Subacromial decompression yields a better clinical outcome than therapy alone: a prospective randomized study with minimum 10-year follow-up. Am J Sports Med. 2018. DOI: 10.1177/0363546518755759
  • Bailie DS, Ellenbecker TS. Severe chondrolysis after shoulder arthroscopy associated with continuous bupivacaine infusion. Arthroscopy. 2009. DOI: 10.1016/j.arthro.2009.08.024
  • (The corpus is thin on no-repair / diagnostic-arthroscopy rehabilitation specifically; the higher-tier evidence below comes from the placebo-controlled surgical trials and published surgeon protocols.)

Literature (URLs)

Published rehab protocols (patient-guidance — basis for the phase structure)

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Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

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.