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Paglilinis ng Matigas na Siko (Arthrolysis)

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Isang maagang, agresibong plano para sa pagbawi ng galaw pagkatapos ng operasyon upang paluwagin ang matigas na siko — ang doktor ay nakakabalik sa pagliko at pagtutuwid sa mesa, at ang buong tungkulin ng rehabilitasyon ay panatilihin ang saklaw na iyon, nagsisimula sa unang araw na walang sling at walang yugto ng proteksyon.

Illustrasyon ng kasukasuan ng siko na nagpapakita ng mga masyadong matigas at mahigpit na ibabaw ng buto at kapsula.
Ang matigas na siko pagkatapos ng sugat o operasyon — ang makapal at masikip na kapsula na binabawasan ng operasyon sa pagpapalaya. 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 gabay sa iyong paggaling pagkatapos ng operasyon upang paluwagin ang matigas na siko (isang release o arthrolysis) kay Dr. Kieran Hirpara sa Mater Private Hospital Rockhampton. Nagsisimula ito sa iyong home exercise program, kasunod ng istrukturadong clinical protocol na isinulat para sa iyong physiotherapist o hand therapist; dalhin ang pahinang ito o ang PDF nito sa iyong unang bisita sa therapy upang manatiling koordinado ang iyong rehabilitation. Maaaring baguhin ng iyong therapist ang plano depende sa pag-unlad ng iyong paggaling.

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

Ano ang inaasahan

Ang matigas na siko pagkatapos ng isang nakaraang sugat o operasyon ay nangyayari dahil ang lining (capsule) ng kasukasuan ay nagpapalaki at naninigas, at minsan ay may nabubong karagdagang buto, kaya hindi na makakabeng beng o makakaluwag ang siko sa kanyang buong saklaw. Sa operasyon ng pagpapalaya, na ginagawa gamit ang keyhole (arthroscopic) na operasyon o sa pamamagitan ng bukas na hiwa, tinatanggal ng doktor ang matigas na capsule (at anumang karagdagang buto o nakulong peklat) upang muling malaya ang siko sa operating table.

Ang pinakamahalagang bagay na unawain ay ang paggaling nito ay kabaligtaran ng isang operasyon ng pagkukumpuni. Walang tinahi o inayos na bahagi na nangangailangan ng linggah-linggo ng pahinga upang gumaling. Sa halip, itinatag ng doktor ang halos buong saklaw ng galaw sa loob ng operasyon, at ang buong tungkulin ng iyong rehabilitasyon ay panatilihin ang galaw na iyon, dahil ang likas na kagustuhan ng siko pagkatapos ng operasyon ay muling magmatigas. Ito ang dahilan kung bakit walang sling at walang yugto ng proteksyon: nagsisimula kang gumalaw ng siko sa unang araw, at matapang at madalas kang gagalawin ito. Ang kaaway dito ay ang muling pagkamatigas, hindi ang pagkabigo ng tisyu.

Para sa pangangalaga sa sugat, pamamahala ng pamamaga at peklat, tingnan ang gabay ng klinika tungkol sa pangangalaga sa sugat. Ang pamamaga at sakit ang pangunahing mga bagay na humahadlang sa galaw sa mga unang araw, kaya ang pagkontrol dito sa pamamagitan ng pagtaas, yelo, at iyong gamot pang-alis ng sakit ay mahalagang bahagi ng pagpapanatili ng iyong saklaw.

Karamihan sa iyong pag-unlad ay nangyayari sa pagitan ng mga 6 linggo at 3 buwan, at karaniwang umaabot ang siko sa kanyang pinakamainam at nakatitirang saklaw sa paligid ng 4 na buwan. Upang mapanatili at kahit dagdagan ang iyong saklaw, ginagamit ang isang programa ng splinting sa gabi at sa mga oras ng pahinga at ito ay patuloy sa loob ng ng hindi bababa sa 3 buwan.

Mga Paalala at Limitasyon

  • Gawin na simulan ang paggalaw ng siko sa unang araw, at patuloy na galawin ito nang bahagya at madalas sa loob ng araw: ito ang pangunahing bahagi ng iyong paggaling.
  • Gawin na dahan-dahang pindutin sa dulo ng bawat stretch; hindi tulad ng pagkumpuni, walang istruktura na protektahan, kaya ang layunin ay abutin ang saklaw ng galaw.
  • Gawin na kontrolin ang pamamaga at sakit sa pamamagitan ng pagtaas, yelo, at ang iyong iniresetang gamot pang-alis ng sakit: sila ang nagbabawal sa iyong paggalaw, hindi ang operasyon mismo.
  • Gawin na uminom ng anumang gamot laban sa pamamaga (tulad ng indomethacin) eksaktong ayon sa inireseta kung si Dr. Hirpara ang nagsimula nito upang pigilan ang sobrang pagbuo ng buto.
  • Gawin na isuot ang iyong splint sa gabi/pahinga ayon sa utos, sa loob ng hindi bababa sa 3 buwan, upang mapanatili at palakasin ang saklaw ng galaw na nakukuha mo.
  • Huwag Gawin na pahingahin ang siko o "mag-ingat" upang payain itang tumigil: doon nagbabalik ang katigasan.
  • Huwag Gawin na mag-alala sa pamamanhid o pangangati papunta sa maliit at ring finger; ang nerbiyos sa loob ng siko (ang ulnar nerve) ay maaaring maging mas sensitibo habang umuunlad ang iyong pagbaluktot, kaya ipaalam ito kay Dr. Hirpara o sa iyong therapist upang ma-review.

Mga ehersisyo

Ito ang mga ehersisyo mula sa iyong handout para sa pagbawi at pagpapanatili ng galaw ng iyong siko at forearms. Simulan ang mga ito ayon sa gabay ni Dr. Hirpara at ng iyong therapist; sa protocol na ito, nagsisimula agad ang mga ito. Gawin ang mga ito nang mahigpit at madalas, dahil ang saklaw na iyong pinapanatili ay ang saklaw na ginagamit mo sa pamamagitan ng mga ehersisyong ito araw-araw.

Ang iyong klinikal na protokol

Ang natitirang bahagi ng pahinang ito ay ang klinikal na protokol para sa rehabilitasyon pagkatapos ng operasyong pagpapalaya (arthrolysis) ng matigas na siko. Ang seksyong ito ay dapat ibigay sa iyong pisyoterapeuta o terapistang pang-kamay, at ang bawat yugto sa ibaba ay may kasamang paliwanag sa simpleng wikang Ingles tungkol sa nangyayari. Ang pangunahing prinsipyo ay ang doktor ang nagtatakda ng halos buong saklaw ng galaw sa mesa; ang tungkulin ng rehabilitasyon ay hindi ito mawalan. Walang kagamitan na kailangang protektahan kaya walang yugto ng proteksyon: ang kontrol sa sakit at pamamaga ang mga nagpapaunlad ng bilis, hindi ang paggaling ng tisyu.

Araw 0 hanggang 2 pagkatapos ng iyong operasyon

Sa unang isang o dalawang araw, pahinga nang kaunti ang siko, itaas ang braso, at kontrolin ang pamamaga gamit ang yelo at compression. Madalas, sinusuportahan ang siko sa ganap na tuwid (extension) na posisyon, dahil ang pagwawasto ang galaw na karaniwang nawawala at ang dapat paboran. Kung may alalahanin sa karagdagang pagbuo ng buto (halimbawa, pagkatanggal ng karagdagang buto, o matinding pinsala sa simula), maaaring simulan ni Dr. Hirpara ang paggamot na may anti-inflammatory upang pigilan ito.

Para sa iyong pisyoterapeuta:

Bago ang paggamot, suriin ang imahen ng pasyente, ulat ng operasyon, at kasaysayan ng medikal na nakaraan (PMHx), at makipag-ugnayan sa nag-ooperahang doktor tungkol sa arc na nakamit sa loob ng operasyon, anumang prosedura sa ulnar nerve, at kung nagsimula na ang prophylaxis laban sa heterotopic ossification (HO).

Posisyon at edema

  • Maikling immobilisasyon sa ganap na extension sa may padding na splint; itaas ang braso; cryotherapy/compression para sa edema
  • Karaniwang tinatanggal ang drains sa POD1

Prophylaxis laban sa HO (kung kinakailangan)

  • Indomethacin (hal. 25 mg TID, o 75–100 mg/araw) sa loob ng 3–6 linggo kung kinakailangan, lalo na pagkatapos ng excision ng HO o matinding trauma; ± single-dose perioperative radiotherapy sa mga piniling kaso ng mataas na panganib (desisyon ng doktor)

Araw 1 pataas — agad-agad na agresibong paggalaw ng saklaw

Ito ang pangunahing bahagi ng protokolo. Inaalisan ng splint ang kamay sa unang araw pagkatapos ng operasyon at simulan ang matibay at madalas na paggalaw: aktibo-inaasistang at pasibong pagliko, pagwawasto, at pag-ikot ng forearms, na may layuning mabawi ang buong saklaw na naabot ng doktor sa mesa. Walang limitasyon sa saklaw: ang layunin ay ang buong intra-operative na arc.

Para sa iyong pisyoterapeuta:

Limitasyon ng ROM

  • Wala. Mabawi ang buong intra-operative na arc. Inaalisan ng splint sa POD1.

Mga ehersisyo

  • Aktibo-inaasistang at pasibong ROM sa flexion, extension, pronation at supination; bigyang-diin ang stretch patungo sa pinakamahigpit na direksyon (karaniwan ay extension)
  • Opsyonal na CPM: kung gagamitin, simulan sa ospital sa POD1–2 sa buong available na saklaw (karaniwang binabanggit na 0–145° na may bolster sa likod ng siko) at ipagpatuloy sa bahay hanggang ~4 linggo, kasama ang PT. Ang CPM ay isang adjunct lamang at hindi ipinapakita na mas epektibo kaysa sa supervised PT; ang paggamit ay nasa diskresyon ng doktor.
  • Dalas: araw-araw na supervised PT sa unang linggo pagkatapos ng operasyon, pagkatapos ay 2–3×/week sa loob ng ~6 linggo

Mga pamantayan para sa pag-progres

  • Panatilihin ang on-table na arc; kontrolado ang oedema at sakit

Linggo 2 hanggang 6 — panatilihin ang arc at ipakilala ang splinting

Ang paggalaw ay patuloy na mahigpit. Upang mapanatili at palakasin ang saklaw, isang programa ng splinting ay idinadagdag sa gabi at sa mga oras ng pahinga: isang mababang-load, matagal na stretch na hawak sa dulo ng saklaw, magpapalit-palit sa pagliko at pagwawasto.

Para sa iyong physiotherapist:

Mga ehersisyo at splinting

  • Patuloyin ang agresibong aktibo / aktibo-nakatutulong / pasibong ROM
  • Magdagdag ng static-progressive (o dynamic / serial-static / turnbuckle) splinting para sa mababang-load na matagal na end-range stretch: isang programa sa gabi/pahinga na nagpapalit-palit ng flexion at extension. Ang static-progressive (inelastic, patient-adjusted incremental torque) ay ang pinakamainam na paraan para sa mga kontraktura ng elbow flexion.
  • Pamamahala ng oedema at peklat

Mga pamantayan para sa pag-progres

  • Ang arc ay napapanatili o higit pa; handa na para sa pag-load sa ~linggo 6

Linggo 6 hanggang 12 — pagpapalakas at patuloy na paggamit ng splint

Kapag matatag na ang galaw, karaniwan sa loob ng 6 linggo, nagsisimula ang pagpapalakas gamit ang progressive resistive exercise ayon sa kakayahang tanggapin. Patuloy ang programang paggamit ng splint.

Para sa iyong pisyikal na terapeuta:

Mga ehersisyo at paggamit ng splint

  • Magsimula ng progressive resistive strengthening kapag matatag na ang galaw (karaniwan sa ~6 linggo)
  • Patuloy na gamitin ang splint ng hindi bababa sa ~3 buwan pagkatapos ng operasyon para sa pinakamainam na final ROM

Mga 16 linggo — plateau

Ang mga publikadong serye ng kaso ay nag-uulat na nakararanas ang mga pasyente ng maksimum na arc ng galaw sa isang average na 16 linggo, habang ang pinakamalaking bahagi ng paggaling ay nangyayari sa pagitan ng 6 linggo at 3 buwan. Dapat itong itakda bago ang operasyon. Ang mga huling pinanatiling pag-unlad sa pagliko/pagwasto at pag-ikot ay karaniwang nananatili sa mahabang panahon (mga 15-buong pagsubaybay sa malalaking kohorte).

Para sa iyong pisyoterapeuta:

  • Ang maximum na arc ay nakararanas sa isang average na ~16 linggo; magbigay ng payo na walang threshold ng range bago ang operasyon ang maaaring maaasahan upang ma-predict ang trajectory ng paggaling; gamitin ang parehong ~16 linggo na timeline sa lahat ng mga pasyente

Pagbabalik sa trabaho at gawain

Dahil walang fixation na kailangang protektahan, ang pagbabalik sa pang-araw-araw na gawain ay nakabase sa iyong kaginhawaan, pamamaga, at saklaw ng galaw na iyong pinapanatili imbes na maghintay na gumaling ang isang bahagi. Ang magaan na paggamit ng braso para sa mga pang-araw-araw na gawain ay inirerekomenda mula sa simula; sa katunayan, ang normal na paggamit ng siko sa loob ng araw ay bahagi ng paggamot.

Ang pagpapalakas ng kalamnan, kasama nito ang mas mabibigat at mas mahihirap na mga gawain, ay nagsisimula sa humigit-kumulang 6 linggo kapag matatag na ang iyong galaw, at dahan-dahang pinapalakas ayon sa iyong lakas at saklaw ng galaw. Karamihan sa mga tao ay nakakamit ang kanilang natatanging saklaw ng galaw at function sa humigit-kumulang 4 na buwan, at karaniwang nananatili ang mga nakamit na resulta sa pangmatagalan. Ang pagbabalik sa pagmamaneho, mga tungkulin sa trabaho, at sports ay nakadepende sa pagbawi ng sapat na galaw, lakas, at kontrol para sa tiyak na gawain; talakayin ang tamang oras para sa iyong sitwasyon kay Dr. Hirpara at sa iyong therapist, dahil ito ay nag-iiba depende sa iyong trabaho at sa lawak ng iyong operasyon. Ang pinakamahalagang mensahe ay panatilihin ang iyong programa ng paggalaw at paggamit ng splint sa gabi/pahinga sa buong proseso, dahil ito ang nagpoprotekta sa saklaw ng galaw na iyong pinaghirapan na mabawi.

Pagkatapos ng iyong protocol

Ang protocol na ito ay nagtatrabaho kasama ng pangkalahatang payo para sa paggaling ng klinika: tingnan ang pamamahala ng post-operative na sakit at pag-aalaga sa sugat. Para sa kaugnay na paggaling ng siko kung saan inilalabas ang lining ng kasu-kasuan, tingnan ang capsular release. Ang phased na plano sa itaas ay naaayon sa publikadong ebidensya tungkol sa rehabilitasyon pagkatapos ng paglabas ng elbow contracture, at ang iyong patuloy na paggaling ay pinamumunuan nang indibidwal ng iyong physiotherapist o hand therapist ayon sa kung paano ang iyong siko ay umaunlad.

Reviewed by Dr Kieran Hirpara · 18 June 2026.

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

Stiff Elbow — Arthrolysis / Capsular Release (Open or Arthroscopic) — Rehabilitation Evidence

Topic scope: rehabilitation after surgical release of the post-traumatic / post-surgical stiff elbow — open or arthroscopic arthrolysis, anterior + posterior capsulectomy, ± heterotopic ossification (HO) excision, ± ulnar nerve decompression. The focus here is the post-operative rehabilitation philosophy and timeline, not the indications for or technique of the release itself.

Defining principle: the surgeon establishes a near-full arc of motion on the operating table; rehabilitation's single job is to not lose it. There is no fixation to protect, so — unlike a fracture fixation or a tendon repair — there is no protection phase. Motion starts essentially Day 1 (or even in-hospital CPM from Day 1–2), pushed firmly and often. Pain and oedema control are the rate-limiters, not tissue healing. This is the opposite philosophy to olecranon ORIF or a distal biceps repair. Dr Hirpara's stance: no sling and no immobilisation phase; immediate aggressive active-assisted and passive ROM from POD1; static-progressive (or dynamic) night/rest splinting continued for at least 3 months; HO prophylaxis where indicated; and a frank pre-operative conversation that the elbow reaches its plateau at a mean of ~16 weeks.

Consensus phased timeline (week windows)

Phase Window Immobilisation / "ceiling" Movement & adjuncts Strengthening Criteria to progress
Immediate Day 0–2 Brief splint in full extension; arm elevated, cryotherapy/compression HO prophylaxis decision made now (see below); drains out POD1 — Splint off POD1
Immediate aggressive ROM (core) Day 1 onward No ROM ceiling — recover the full intra-operative arc Active-assisted + passive flexion / extension / pronation / supination; bias toward tightest direction (usually extension). Optional CPM 0–145° with bolster, in-hospital POD1–2, home to ~4 wk. Daily PT first week → 2–3×/wk for ~6 wk — On-table arc maintained; oedema/pain controlled
Hold the arc + splinting Weeks 2–6 None Continue aggressive A/AAROM/PROM. Add static-progressive (or dynamic / serial-static / turnbuckle) splinting — low-load prolonged end-range stretch, night/rest, alternating flexion/extension — Arc maintained or exceeded; ready for loading ~wk 6
Strengthening + continued splinting Weeks 6–12 None Continue splinting Progressive resistive strengthening once motion stable (~wk 6); continue splinting ≥3 months Stable, strengthening motion
Plateau ~16 weeks (≈4 months) None — Maintain gains; long-term hold Maximum arc reached; most recovery occurred 6 wk–3 mo

Evidence summary by theme

Immediate aggressive motion — the agreed principle (Strong consensus)

Large, consistent retrospective case series and review articles agree that the elbow re-stiffens without immediate motion, and that rehabilitation exists to hold the intra-operative arc. Motion begins POD1; the splint (when used) is removed POD1 and active-assisted + passive ROM is started in all planes, biased toward the tightest direction (usually extension). This is strong consensus across the literature.

Which specific rehab protocol is best (Moderate — genuine equipoise)

The best specific rehab protocol is genuinely unknown. No completed RCT shows superiority of CPM vs PT vs delayed PT — the SET-Study (Stiff Elbow Trial) was designed precisely because this question is unresolved, with three real-world arms (in-hospital CPM + early PT / in-hospital early PT / outpatient PT from POD7–10). CPM is cited in protocols (home use to ~4 weeks) and one arthroscopic- release series reports very good 3-year outcomes with a 4-week CPM rail plus PT, but CPM has never been shown superior to supervised PT alone. So: strong consensus on aggressive early motion; weak/equipoise evidence on which adjunct.

Splinting modality (Moderate — no clear winner)

Static-progressive, dynamic, serial-static and turnbuckle splinting all deliver low-load prolonged end-range stretch. The Lindenhovius RCT found no difference between dynamic orthoses and static-progressive splinting (similar DASH). Static-progressive (inelastic, patient-adjusted incremental torque) is the favoured modality for elbow flexion contractures. Reviews recommend the splinting program run for at least ~3 months post-operatively for optimal final ROM. Bracing alone can rival surgery for non-osseous stiffness with far lower neurovascular risk.

HO prophylaxis (Consensus — extrapolated evidence)

Indomethacin (commonly 25 mg TID, or 75–100 mg/day, for 3–6 weeks) ± single-dose perioperative radiotherapy is widely used after release, especially with HO excision or high-energy trauma. Most HO-prophylaxis RCT evidence is extrapolated from acetabular/hip surgery, not elbow-specific. Recurrent HO / arthrofibrosis responds to repeat excision + release.

Recovery trajectory and plateau (Moderate — cohort data)

Published series report patients reach their maximum arc of motion at a mean of ~16 weeks, with most recovery occurring between 6 weeks and 3 months, and maintained gains at ~15-month follow-up in large cohorts. Growth-mixture modelling found no pre-operative ROM threshold or factor reliably predicted the recovery trajectory — so all patients are counselled on the same ~16-week timeline pre-operatively.

Ulnar nerve (Consensus)

As flexion improves post-release, the ulnar nerve sees increased stress — there should be a low threshold for review, and for concomitant ulnar nerve decompression/transposition at the time of surgery. Tobacco use predicts poorer outcomes and higher complication rates after open arthrolysis.

Evidence strength flags (summary)

  • STRONG (consensus across case series/reviews): immediate aggressive active-assisted + passive motion from POD1 to hold the intra-operative arc — no protection phase.
  • MODERATE (RCT/cohort, equipoise): which adjunct is best — CPM vs PT vs delayed PT (SET-Study, no completed superiority data); splinting modality (Lindenhovius RCT: no difference dynamic vs static-progressive); ~16-week plateau and maintained gains (growth-mixture-modelling and large open-release cohorts).
  • CONSENSUS / EXTRAPOLATED: HO prophylaxis (indomethacin ± single-dose RT; most evidence extrapolated from acetabular/hip surgery); ≥3-month splinting program duration.

Overall topic flag: MODERATE — strong consensus on the principle (aggressive early motion + adjunct splinting + HO prophylaxis), weak/equipoise evidence on the specific adjunct.

CITATIONS

RAG corpus (180,000+ Orthopaedic articles)

  • Sun Z, Wang W, Fan C. Tobacco use predicts poorer clinical outcomes and higher post-operative complication rates after open elbow arthrolysis. Arch Orthop Trauma Surg. 2019.
  • Open elbow release for post-traumatic stiffness — growth-mixture-modelling cohort: maximum arc of motion at a mean of ~16 weeks, most recovery between 6 weeks and 3 months.
  • 103-patient open capsular release series — significant, maintained flexion/extension and supination/pronation arc gains at a mean of 15 months.
  • Papatheodorou LK, Sotereanos DG (University of Pittsburgh) — elbow contracture release techniques review.
  • Lindenhovius et al. RCT — no difference between dynamic orthoses and static-progressive splinting (cited within a retrieved review).
  • Retrieved technique text: indomethacin 25 mg TID for ~6 weeks for HO prophylaxis; CPM continued at home up to 4 weeks, full range 0–145° with a bolster behind the elbow.
  • Northwestern series — HO excision + contracture release: ROM gains and complications.
  • Arthroscopic release + 4-week CPM rail series — very good ROM, function and quality of life at a mean of 3 years.

Published protocols / reviews (URLs)

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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.