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Libertação do Cotelo Rígido (Artrolise)

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Um plano de recuperação de movimento precoce e agressivo após uma cirurgia para liberar um cotovelo rígido — o cirurgião recupera a flexão e a extensão na mesa, e todo o trabalho de reabilitação é manter essa amplitude de movimento, começando desde o primeiro dia, sem talas e sem fase de proteção.

Ilustração da articulação do cotovelo mostrando as superfícies ósseas e a cápsula que podem se tornar rígidas e contraturas.
Cotovelo rígido após lesão ou cirurgia — a cápsula espessada e contrátil que uma operação de liberação libera. Kieran Hirpara 4.0

Esta página foi traduzida automaticamente e ainda não foi verificada por um médico. A versão em inglês é a versão oficial.

Este protocolo orienta a sua recuperação após uma cirurgia para libertar um cotovelo rígido (uma libertação, ou artrolise) com o Dr. Kieran Hirpara no Mater Private Hospital Rockhampton. Começa com o seu programa de exercícios em casa, seguido pelo protocolo clínico estruturado escrito para o seu fisioterapeuta ou terapeuta da mão; traga esta página ou o seu PDF para a sua primeira sessão de terapia, para que a sua reabilitação seja coordenada. O seu terapeuta pode ajustar o plano, dependendo da forma como a sua recuperação progride.

Se tiver alguma preocupação sobre a sua ferida após a cirurgia, entre em contacto com a clínica. É frequentemente útil tirar uma fotografia da ferida e enviá-la por e-mail para avaliação.

O que esperar

Um cotovelo rígido após uma lesão ou cirurgia prévia ocorre porque o revestimento (cápsula) da articulação espessa e contrai, e por vezes forma-se osso adicional, impedindo que o cotovelo dobre e estique completamente. Durante a cirurgia de libertação, realizada por cirurgia artroscópica (por chave) ou através de uma incisão aberta, o cirurgião remove essa cápsula contráctil (e qualquer osso extra ou cicatriz aprisionada) para que o cotovelo volte a mover-se livremente na mesa de operações.

O aspeto mais importante a compreender é que esta recuperação é o oposto de uma cirurgia de reparação. Não há nada que tenha sido suturado ou fixado que necessite de semanas de repouso para sarar. Em vez disso, o cirurgião estabelece um arco de movimento quase completo durante a operação, e a tarefa principal da sua reabilitação é manter esse movimento, porque a tendência natural do cotovelo após a cirurgia é voltar a ficar rígido. É por isso que não há tala nem fase de proteção: começa a mover o cotovelo no primeiro dia, e move-o com firmeza e frequência. O inimigo aqui é o retorno da rigidez, e não a falha dos tecidos.

Para a gestão da ferida, inchaço e cicatrizes, consulte as orientações da clínica sobre cuidados com a ferida. O inchaço e a dor são os principais fatores que limitam o movimento nos primeiros dias, pelo que o seu controlo através da elevação, gelo e medicação analgésica é uma parte importante para manter o arco de movimento.

A maior parte da sua melhoria ocorre entre as 6 semanas e os 3 meses, e o cotovelo atinge geralmente o seu melhor arco de movimento estabilizado por volta dos 4 meses. Para manter e até aumentar o seu arco de movimento, é utilizado um programa de imobilização (splinting) durante a noite e nos períodos de repouso, que é continuado por pelo menos 3 meses.

Precauções e limitações

  • Faça iniciar a mobilização do cotovelo no primeiro dia, e mantenha-o em movimento, pouco e frequentemente ao longo do dia: esta é a base da sua recuperação.
  • Faça pressionar suavemente até ao final de cada alongamento; ao contrário de uma reparação, não há uma construção para proteger, pelo que atingir a amplitude de movimento é o objetivo.
  • Faça controlar o inchaço e a dor com elevação, gelo e a medicação analgésica prescrita: são estes fatores que limitam o seu movimento, e não a cirurgia em si.
  • Faça tomar qualquer medicação anti-inflamatória (como a indometacina) exatamente conforme prescrito, se o Dr. Hirpara a tiver iniciado para evitar a formação de osso extra.
  • Faça usar a tala noturna/de repouso conforme indicado, durante pelo menos 3 meses, para manter e consolidar a amplitude de movimento conquistada.
  • Não faça repousar o cotovelo ou "poupar" a articulação para a deixar estabilizar: é assim que a rigidez volta.
  • Não se alarme com formigueiro ou dormência nos dedos mínimo e anelar; o nervo no lado medial do cotovelo (o nervo ulnar) pode tornar-se mais sensível à medida que a flexão melhora, pelo que deve informar o Dr. Hirpara ou o seu terapeuta para que possa ser reavaliado.

Seus exercícios

Estes são os exercícios do seu material para recuperar e manter a mobilidade do cotovelo e do antebraço. Inicie-os conforme orientado pelo Dr. Hirpara e seu fisioterapeuta; neste protocolo, eles começam imediatamente. Eles devem ser realizados com firmeza e frequência, pois a amplitude que você mantém é a amplitude que utilizará por meio desses exercícios diariamente.

Seu protocolo clínico

O restante desta página é o protocolo clínico de reabilitação após a liberação cirúrgica (artrolise) de um cotovelo rígido. Esta seção deve ser fornecida ao seu fisioterapeuta ou terapeuta da mão, e cada uma das fases abaixo inicia-se com uma explicação em linguagem simples do que está ocorrendo. O princípio fundamental é que o cirurgião estabelece um arco de movimento próximo ao completo na mesa de cirurgia; o papel da reabilitação é não perder esse arco. Não há fixação a proteger e, portanto, não há fase de proteção: o controle da dor e do edema são os limitadores da taxa de progresso, e não a cicatrização tecidual.

Dia 0 a 2 após a sua cirurgia

No primeiro ou segundo dia, o cotovelo é mantido em repouso breve, o braço é mantido elevado e o inchaço é controlado com gelo e compressão. O cotovelo é frequentemente suportado numa posição de completa extensão, porque a extensão é o movimento mais comumente perdido e aquele para o qual se deve tender. Se a formação óssea extra for uma preocupação (por exemplo, após remoção de osso extra, ou uma lesão original de alta energia), o Dr. Hirpara pode iniciar uma medicação anti-inflamatória agora para a desencorajar.

Para o seu fisioterapeuta:

Antes do tratamento, verifique as imagens do paciente, o relatório cirúrgico e o histórico médico prévio (HMP), e entre em contacto com o cirurgião tratante relativamente ao arco intra-operatório alcançado, qualquer procedimento no nervo ulnar, e se a profilaxia de ossificação heterotópica (OH) foi iniciada.

Posição e edema

  • Imobilização breve em extensão completa com talco acolchoado; braço elevado; crioterapia/compressão para edema
  • Drenos tipicamente removidos no DPC1

Profilaxia de OH (se indicada)

  • Indometacina (por exemplo, 25 mg 3 vezes ao dia, ou 75–100 mg/dia) durante 3–6 semanas quando indicado, especialmente após excisão de OH ou trauma de alta energia; ± radioterapia perioperatória em dose única em casos selecionados de alto risco (decisão do cirurgião)

A partir do dia 1 — mobilização ativa agressiva imediata

Este é o cerne do protocolo. A tala é removida no primeiro dia pós-operatório e inicia-se o movimento firme e frequente: flexão, extensão e rotação do antebraço assistida ativamente e passivamente, com o objetivo de recuperar a amplitude total que o cirurgião alcançou na mesa cirúrgica. Não há limite de amplitude: o objetivo é a arco completo intraoperatório.

Para o seu fisioterapeuta:

Limite de amplitude (ROM)

  • Nenhum. Recuperar o arco completo intraoperatório. Remoção da tala no DPO1.

Exercícios

  • ROM assistida ativamente e passiva em flexão, extensão, pronação e supinação; direcionar o alongamento para a direção mais restrita (geralmente extensão)
  • CPM opcional: se utilizado, iniciar no hospital no DPO1–2 com a amplitude disponível completa (comumente citada como 0–145° com um suporte atrás do cotovelo) e continuar em casa até ~4 semanas, além da fisioterapia. A CPM é apenas um coadjuvante e não foi demonstrada superior à fisioterapia supervisionada; o uso é discricionário do cirurgião.
  • Frequência: fisioterapia supervisionada diária na primeira semana pós-operatória, depois 2–3×/semana por ~6 semanas

Critérios para progressão

  • Manutenção do arco na mesa cirúrgica; edema e dor controlados

Semanas 2 a 6 — manter o arco e introduzir a talas

O movimento continua de forma firme. Para manter e desenvolver a amplitude de movimento, é adicionado um programa de talas à noite e nos períodos de repouso: um alongamento prolongado de baixa carga mantido no final do arco, alternando entre flexão e extensão.

Para o seu fisioterapeuta:

Exercícios e talas

  • Continuar a amplitude de movimento (ROM) ativa agressiva / ativa-assistida / passiva
  • Adicionar talas estático-progressivas (ou dinâmicas / seriadas-estáticas / de manivela) para alongamento prolongado de baixa carga no final do arco: um programa noturno/de repouso alternando flexão e extensão. As talas estático-progressivas (torque incremental inelástico, ajustado pelo paciente) são o modalidade preferida para contraturas de flexão do cotovelo.
  • Manejo do edema e da cicatriz

Critérios para progressão

  • Arco mantido ou excedido; pronto para carga por volta da semana 6

Semanas 6 a 12 — fortalecimento e uso contínuo da órtese

Assim que o movimento estiver estável, geralmente por volta das 6 semanas, inicia-se o fortalecimento com exercícios resistidos progressivos, conforme a tolerância. O programa de uso da órtese continua.

Para o seu fisioterapeuta:

Exercícios e uso da órtese

  • Iniciar o fortalecimento resistido progressivo assim que o movimento estiver estável (tipicamente ~6 semanas)
  • Continuar o uso da órtese por pelo menos ~3 meses no pós-operatório para um ROM final ideal

Por volta de 16 semanas — platô

Séries publicadas relatam que os pacientes atingem seu arco máximo de movimento em uma média de aproximadamente 16 semanas, com a maior parte da recuperação ocorrendo entre 6 semanas e 3 meses. Essa expectativa deve ser estabelecida no pré-operatório. Os ganhos finais mantidos nos arcos de flexão/extensão e rotação são tipicamente preservados a longo prazo (acompanhamento de aproximadamente 15 meses em grandes coortes).

Para o seu fisioterapeuta:

  • Arco máximo atingido em uma média de ~16 semanas; orientar que nenhum limiar pré-operativo de amplitude de movimento prevê de forma confiável a trajetória de recuperação; aplicar o mesmo cronograma de ~16 semanas a todos os pacientes

Retornar ao trabalho e às atividades

Como não há fixação para proteger, o retorno às atividades do dia a dia é guiado pelo seu conforto, inchaço e amplitude de movimento que você está mantendo, em vez de esperar por alguma estrutura cicatrizar. O uso leve do braço para tarefas diárias é incentivado desde o início; de fato, o uso normal do cotovelo ao longo do dia faz parte do tratamento.

O fortalecimento, e com ele tarefas mais pesadas e exigentes, começa por volta das 6 semanas, quando o seu movimento estiver estável, e é progressivamente aumentado conforme sua força e amplitude de movimento permitirem. A maioria das pessoas atinge sua amplitude e função estáveis por volta dos 4 meses, e os ganhos obtidos são tipicamente mantidos a longo prazo. O retorno à direção, às funções laborais e aos esportes depende da recuperação de movimento, força e controle suficientes para a tarefa específica; discuta o momento adequado para o seu caso com o Dr. Hirpara e seu terapeuta, pois isso varia conforme sua profissão e a extensão da sua cirurgia. A mensagem mais importante é manter o programa de mobilização e de uso de tala noturna/em repouso durante todo o período, pois é isso que protege a amplitude de movimento que você se esforçou para recuperar.

Após o seu protocolo

Este protocolo complementa as orientações gerais de recuperação da clínica: consulte o controlo da dor pós-operatória e os cuidados com a ferida. Para uma recuperação do cotovelo relacionada em que o revestimento articular é libertado, consulte a libertação capsular. O plano por fases acima descrito está em conformidade com a evidência publicada sobre a reabilitação após libertação de contratura do cotovelo, e a sua recuperação contínua é orientada individualmente pelo seu fisioterapeuta ou terapeuta da mão, de acordo com a evolução do seu cotovelo.

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. 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.

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