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Psychosocial Factors & Screening in Musculoskeletal Recovery

Barriers to rehabilitation engagement and recovery — kinesiophobia, fear-avoidance, catastrophising, distress, significant disability. Psychosocial screening (Örebro, STarT-Back). Return-to-work factors. Why some patients plateau earlier than expected.

Overview

Early in the care of orthopaedic trauma, there exists an opportunity to improve overall health by attending to psychological and social concerns, along with physical health [1]. Early consideration of factors that affect psychological prognosis is needed for the upper extremity limb salvage population [2], a group among the first to have such outcomes examined [14]. In patients with ulnar-sided wrist pathology, a more negative psychosocial profile was associated with higher pain levels and dysfunction preoperatively and postoperatively [3].

Despite these associations, patients with a more negative psychosocial profile showed similar improvement as patients with a more feasible psychosocial profile following surgery for ulnar-sided wrist pathology [3]. Psychosocial factors were not associated with patient-reported outcomes after intervention for rotator cuff tears [4]. Understanding the effect of mental health on surgical outcomes and the potential benefits of psychological intervention may represent an opportunity to improve patient outcomes following hip arthroscopy [7]. Surviving patients of hip fractures experience measurable gains in function and well-being in the 3 years after the fracture [5].

Hand therapists play a critical role in facilitating physical and psychosocial recovery by using patient-centered, culturally relevant assessments and interventions to positively affect adjustment and improve outcomes [11].

Anatomy & Pathophysiology

Orthopaedic surgeons are best positioned to recognize and prevent posttraumatic stress disorders, thereby improving patient outcomes [13]. Several psychological and physiological factors predicted change in the number of musculoskeletal pain sites among Norwegian employees [17]. The overall validity of the short clinical questionnaire on work-related psychosocial risk factors ("Blue flags") is considered acceptable [44].

Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint, often associated with mechanical block from periarticular osteophytes [22]. Patients with chronic whiplash showed evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli [46]. Therapists appear to be biomechanically oriented, which may impact outcomes in the use of psychosocial services post hand and upper limb injury and trauma [27]. Arm pain without physical signs related to light repetitive work remains a hopelessly confused medical area with no reason to believe it will change as good scientific data are not forthcoming [34].

Classification

Psychosocial Screening: Early orthopaedic trauma care presents an opportunity to improve overall health by addressing psychological and social concerns alongside physical health [1]. For upper extremity limb salvage, early consideration of factors affecting psychological prognosis is necessary [2]. In patients with ulnar-sided wrist pathology, a more negative psychosocial profile correlates with higher preoperative and postoperative pain levels and dysfunction [3], though these patients demonstrate similar postoperative improvement as those with a feasible profile [3]. Conversely, psychosocial factors do not predict patient-reported outcomes following rotator cuff tear intervention [4].

Work-Related & Demographic Factors: Numerous injury-related and psychosocial factors influence the duration of time away from work following orthopaedic injury [8]. Occupational groups and psychosocial working conditions serve as risk factors for disability pension due to musculoskeletal diagnoses [10]. Demographic variables, including advanced age, low family income, and multiple medical conditions, significantly affect scores on knee symptom evaluation systems [12]. Among Norwegian employees, several psychological and physiological factors predict changes in the number of musculoskeletal pain sites [17].

Recovery Trajectories & Classification Systems: Survivors of hip fractures experience measurable gains in function and well-being over the three years post-fracture [5]. Patients with motor vehicle-related orthopaedic trauma exhibit poor injury recovery, particularly regarding mental health, irrespective of claim status [16]. The increase in health-related quality of life (HRQoL) is lower in subgroups with an incident fracture but remains uninfluenced by recent prior fractures [21]. A multidimensional approach classifying psychological and psychosocial characteristics can distinguish different groups in working populations with neck and/or low back pain [25]. However, a risk classification schema using recommended cut-off scores with items similar to the STarT-Back in a primary care population with strictly defined acute low back pain demonstrates limited ability to identify persons progressing to chronic pain [26].

Other Considerations: Evidence indicates that a multidimensional approach based on psychological and psychosocial characteristics can distinguish different groups in a working population with neck and/or low back pain [25].

Clinical Presentation

Early in the care of orthopaedic trauma, there exists an opportunity to improve overall health by attending to psychological and social concerns, along with physical health [1]. Early consideration of factors that affect psychological prognosis is needed for the upper extremity limb salvage population [2]. Many injury-related and psychosocial factors affect the duration of time away from work following orthopaedic injury [8]. Occupational groups and psychosocial working conditions represent risk factors for disability pension due to musculoskeletal diagnoses [10].

Psychosocial profiles correlate with specific clinical outcomes depending on the pathology. A more negative psychosocial profile was associated with higher pain levels and dysfunction preoperatively and postoperatively in patients with ulnar-sided wrist pathology [3], yet these patients showed similar improvement as those with a more feasible profile following surgery [3]. Conversely, psychosocial factors were not associated with patient-reported outcomes after intervention for rotator cuff tears [4]. Demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores on scoring systems for total knee arthroplasty [12].

Screening for mental health conditions is critical given the high prevalence of poor recovery in specific trauma cohorts. Irrespective of claim status, the majority of patients with motor vehicle related orthopaedic trauma had poor injury recovery, especially for mental health [16]. Surviving patients of hip fractures experience measurable gains in function and well-being in the 3 years after the fracture [5], and understanding the effect of mental health on surgical outcomes may represent an opportunity to improve patient outcomes following hip arthroscopy [7]. Orthopaedic surgeons are best positioned to recognize and prevent posttraumatic stress disorder (PTSD) [13].

Screening Tools & Timing: * Timing: Screening at 3 months may detect posttraumatic stress disorder, anxiety, depression, and chronic pain following hand trauma [18]. * Örebro Musculoskeletal Pain Questionnaire (ÖMPQ): This 'yellow flag' screening tool predicts long-term disability and failure to return to work when completed four to 12 weeks following a soft tissue injury [19]. * Specific Indicators: Patients who respond positively to the item, 'The emotional problems caused by the injury have been more difficult than the physical problems,' may meet diagnostic criteria for posttraumatic stress disorder and should be evaluated further [28]. * Specialized Tools: The SA-Q questionnaire has potential clinical implications for detected changes concerning the different items during rehabilitation for patients with scapula alata [29].

Effective communication with patients regarding treatment modalities, risks and benefits, and prognosis of their injury is important following humeral fractures [15]. Hand therapists play a critical role in facilitating physical and psychosocial recovery by using patient-centered, culturally relevant assessments and interventions to positively affect adjustment and improve outcomes [11]. Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture [9].

Investigations

Other Considerations: Early care of orthopaedic trauma presents an opportunity to improve overall health by attending to psychological and social concerns alongside physical health [1]. Early consideration of factors affecting psychological prognosis is needed for the upper extremity limb salvage population [2], a group among the first to have psychological outcomes examined in this context [14]. A more negative psychosocial profile is associated with higher pain levels and dysfunction preoperatively and postoperatively in patients with ulnar-sided wrist pathology [3], yet these patients show similar improvement as those with a more feasible psychosocial profile following surgery [3]. Conversely, psychosocial factors were not associated with patient-reported outcomes after intervention for rotator cuff tears [4]. Many injury-related and psychosocial factors affect the duration of time away from work following orthopaedic injury [8]. Surviving patients of hip fractures experience measurable gains in function and well-being in the 3 years after the fracture [5]. Irrespective of claim status, the majority of patients with motor vehicle-related orthopaedic trauma had poor injury recovery, especially for mental health [16]. Several psychological and physiological factors predicted change in the number of musculoskeletal pain sites among Norwegian employees [17]. The increase in health-related quality of life (HRQoL) was lower in subgroups with incident fracture but was not influenced by recent prior fracture in breast cancer patients [21]. Orthopaedic surgeons are best positioned to recognize and prevent posttraumatic stress disorder (PTSD) [13]. Effective communication with patients regarding treatment modalities, risks and benefits, and prognosis of their injury is important following humeral fractures [15]. Advanced head imaging for evaluation of total joint arthroplasty patients with a change in mental status is of low yield [32].

Treatment

Early management of orthopaedic trauma offers a critical opportunity to improve overall health by addressing psychological and social concerns alongside physical recovery [1]. For upper extremity limb salvage, early consideration of factors influencing psychological prognosis is essential [2]. In patients with ulnar-sided wrist pathology, a more negative psychosocial profile correlates with higher preoperative and postoperative pain levels and dysfunction [3]; however, these patients demonstrate similar improvement following treatment compared to those with a feasible psychosocial profile [3]. Conversely, psychosocial factors do not appear associated with patient-reported outcomes following rotator cuff tear intervention [4].

Indications: Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara [33].

Setting of Care: Patients may require longer recovery periods from outpatient surgery than previously recognized [20]. Screening at 3 months post-hand trauma is recommended to detect posttraumatic stress disorder, anxiety, depression, and chronic pain [18].

Adjuncts: Hand therapists play a critical role in facilitating physical and psychosocial recovery by utilizing patient-centered, culturally relevant assessments and interventions to positively affect adjustment and improve outcomes [11]. Effective communication regarding treatment modalities, risks, benefits, and prognosis is vital following humeral fractures [15]. Understanding the impact of mental health on surgical outcomes and the potential benefits of psychological intervention represents an opportunity to improve results following hip arthroscopy [7]. Survivors of hip fractures experience measurable gains in function and well-being within the 3 years following the fracture [5].

Complications

Other Considerations: Early orthopaedic trauma care presents a critical opportunity to improve overall health by addressing psychological and social concerns alongside physical management [1]. In the upper extremity limb salvage population, early assessment of factors influencing psychological prognosis is essential [2]. For patients with ulnar-sided wrist pathology, a more negative psychosocial profile correlates with higher preoperative and postoperative pain levels and dysfunction, though these patients demonstrate similar improvements following surgery compared to those with a feasible psychosocial profile [3]. Conversely, psychosocial factors do not appear associated with patient-reported outcomes following rotator cuff tear intervention [4]. Mental health status significantly impacts the duration of time away from work after orthopaedic injury [8], and occupational groups combined with psychosocial working conditions serve as independent risk factors for disability pension due to musculoskeletal diagnoses, distinct from familial confounding [10]. Demographic variables, including advanced age, low family income, and multiple medical conditions, significantly influence scores on various knee symptom evaluation systems [12]. Understanding the impact of mental health on surgical outcomes and the potential benefits of psychological intervention may offer opportunities to improve results following hip arthroscopy [7]. While surviving hip fracture patients experience measurable gains in function and well-being over three years post-fracture [5], long-term data remain necessary to assess the survivorship of the Discovery Elbow System following total elbow arthroplasty [6]. Additionally, distal release of the deltoid muscle contracture yielded good clinical results in 47 of 49 shoulders (96 per cent) [9].

Recovery

Light activity (weeks): While specific week ranges for light activity are not defined in the current evidence base, patients may take longer to recover from outpatient surgery than previously recognized [20]. Early in the care of orthopaedic trauma, there exists an opportunity to improve overall health by attending to psychological and social concerns, along with physical health [1].

Full activity (months): Many injury-related and psychosocial factors affect the duration of time away from work following orthopaedic injury [8]. Occupational groups and psychosocial working conditions represent risk factors for disability pension due to musculoskeletal diagnoses [10].

Complete recovery / outcome plateau (months): Surviving patients of hip fractures experience measurable gains in function and well-being in the 3 years after the fracture [5]. Understanding the effect of mental health on surgical outcomes and the potential benefits of psychological intervention may represent an opportunity to improve patient outcomes following hip arthroscopy [7].

Rehabilitation protocol: There is a need for early consideration of factors that affect psychological prognosis for the upper extremity limb salvage population [2].

Functional milestones: A more negative psychosocial profile was associated with higher pain levels and dysfunction preoperatively and postoperatively in patients with ulnar-sided wrist pathology [3]. Patients with a more negative psychosocial profile showed similar improvement as patients with a more feasible psychosocial profile following surgery for ulnar-sided wrist pathology [3]. Psychosocial factors were not associated with patient-reported outcomes after intervention for rotator cuff tears [4]. The Musculoskeletal Function Assessment Questionnaire was more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values [41].

Other Considerations: The Örebro Musculoskeletal Pain Questionnaire is a 'yellow flag' screening tool that predicts long-term disability and failure to return to work when completed four to 12 weeks following a soft tissue injury [19].

Key Evidence

  • [L5] Early in the care of orthopaedic trauma, there exists an opportunity to improve overall health by attending to psychological and social concerns, along with physical health. (10.5435/jaaos-d-20-00637)
  • [L4] This study indicates the need for early consideration to factors that affect psychological prognosis for the UE limb salvage population. (10.1016/j.jht.2017.05.020)
  • [L3] A more negative psychosocial profile was associated with higher pain levels and dysfunction preoperatively and postoperatively, but these patients showed similar improvement as patients with a more feasible psychosocial profile. (10.1186/s12891-022-05045-x)
  • [L2] However, these factors were not associated with patient-reported outcomes after intervention. (10.1007/s11999.0000000000000087)
  • [L2] Although mortality is high, surviving patients experience measurable gains in function and well-being in the 3 years after the fracture. (10.5435/jaaos-d-19-00530)
  • [L4] Long-term results are required to assess the survivorship of this system. (10.1016/j.jse.2014.08.013)
  • [L1] Understanding both the effect of mental health on surgical outcomes and the potential benefits of psychological intervention may represent an opportunity to improve patient outcomes following hip arthroscopy. (10.1016/j.arthro.2022.05.003)
  • [L2] Many injury-related and psycho social factors affect the duration of time away from work following orthopaedic injury. (10.1186/1471-2474-11-6)
  • [L3] Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture. (10.2106/00004623-199802000-00010)
  • [L2] Occupational groups and psychosocial working conditions seem to be independent of familial confounding, and hence represent risk factors for disability pension due to musculoskeletal diagnoses. (10.1186/1471-2474-14-268)
  • [L5] Hand therapists play a critical role in facilitating physical and psychosocial recovery by using patient-centered, culturally relevant assessments and interventions to positively affect adjustment and improve outcomes. (10.1016/j.jht.2010.11.001)
  • [L4] Numerous scoring systems have been devised to evaluate patients who have symptoms related to the knee, but demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores. (10.2106/00004623-199706000-00009)
  • [L4] Orthopaedic surgeons are best positioned to recognize and prevent PTSD, thereby improving patient outcomes. (10.5435/00124635-201109000-00001)
  • [L4] This study is among the first to examine psychological outcomes for the UE limb salvage population. (10.1016/j.jht.2017.09.003)
  • [L4] These findings highlight the importance of effective communication with patients regarding treatment modalities, risks and benefits, and prognosis of their injury. (10.1177/17585732231201976)
  • [L2] Irrespective of claim status, the majority had poor injury recovery, especially for mental health. (10.1186/s12891-016-1152-2)
  • [L2] Several psychological and physiological factors predicted change in the number of pain sites. (10.1186/s12891-017-1503-7)
  • [L4] Despite a limited evidence base, screening at 3 months may detect posttraumatic stress disorder, anxiety, depression, and chronic pain, potentially allowing for early intervention and improved treatment outcomes. (10.1016/j.jht.2016.11.006)
  • [L2] Patients may take longer to recover from outpatient surgery than previously recognized. (10.1007/s11999-013-3270-6)
  • [L3] The increase in HRQoL was lower in the subgroups with incident fracture but was not influenced by recent prior fracture. (10.1186/1477-7525-7-11)
  • [L5] Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint, often associated with mechanical block from periarticular osteophytes. (10.2106/00004623-199806000-00015)
  • [L2] The study shows that a multidimensional approach to classification based on psychological and psychosocial characteristics can distinguish different groups in a working population with neck and/or low back pain. (10.1186/1471-2474-12-81)
  • [L2] A risk classification schema using the recommended cut-off scores with items similar to the STarT-Back in a primary care population with strictly defined acute LBP had limited ability to identify persons who progressed to chronic pain. (10.1002/ejp.615)
  • [L4] Therapists appear to be biomechanically oriented which may impact outcomes. (10.1177/1558944717725373)
  • [L2] Patients who respond positively to the item, 'The emotional problems caused by the injury have been more difficult than the physical problems,' may meet diagnostic criteria for this disorder and should be evaluated further. (10.2106/00004623-200406000-00001)
  • [L4] The SA-Q questionnaire has potential clinical implications for detected changes concerning the different items during rehabilitation. (10.1186/s12891-020-03284-4)
  • [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
  • [L5] Arm pain without physical signs related to light repetitive work remains a hopelessly confused medical area with no reason to believe it will change as good scientific data are not forthcoming; however, UK courts now recognize this condition as a compensable injury, requiring physicians to be meticulous in examinations and avoid loose diagnostic labeling. (10.1054/jhsb.2000.0517)
  • [L3] It was more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values. (10.2106/00004623-199709000-00006)
  • [L4] In summary, the overall validity is considered acceptable. (10.1186/s12891-017-1677-z)
  • [L4] The patients with chronic WAD showed evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli. (10.1186/1471-2474-11-29)

References

[1] The Psychological Effects of Musculoskeletal Trauma. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00637

[2] Psychosocial reactions to upper extremity limb salvage: A cross-sectional study. Journal of Hand Therapy. 2018. DOI: 10.1016/j.jht.2017.05.020

[3] The impact of psychosocial variables on initial presentation and surgical outcome for ulnar-sided wrist pathology: a cohort study with 1-year follow-up. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05045-x

[4] Are Psychosocial Factors Associated With Patient-reported Outcome Measures in Patients With Rotator Cuff Tears? A Systematic Review. Clinical Orthopaedics & Related Research. 2018. DOI: 10.1007/s11999.0000000000000087

[5] The Pronounced Impact of Hip Fractures on Psychosocial Well-being. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-19-00530

[6] Total elbow arthroplasty: a prospective clinical outcome study of Discovery Elbow System with a 4-year mean follow-up. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.08.013

[7] The Influence of Psychosocial Factors on Hip Surgical Disorders and Outcomes After Hip Arthroscopy: A Systematic Review. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.05.003

[8] Bio-psychosocial determinants of time lost from work following non life threatening acute orthopaedic trauma. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-6

[9] Contracture of the Deltoid Muscle. The Journal of Bone and Joint Surgery (American Volume). 1998. DOI: 10.2106/00004623-199802000-00010

[10] Register-based data of psychosocial working conditions and occupational groups as predictors of disability pension due to musculoskeletal diagnoses: a prospective cohort study of 24 543 Swedish twins. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-268

[11] Psychosocial Issues after a Traumatic Hand Injury: Facilitating Adjustment. Journal of Hand Therapy. 2011. DOI: 10.1016/j.jht.2010.11.001

[12] Demographic Biases of Scoring Instruments for the Results of Total Knee Arthroplasty. The Journal of Bone & Joint Surgery*. 1997. DOI: 10.2106/00004623-199706000-00009

[13] Posttraumatic Stress Disorders in Civilian Orthopaedics. American Academy of Orthopaedic Surgeon. 2011. DOI: 10.5435/00124635-201109000-00001

[14] Psychosocial reactions to upper extremity limb salvage: A case series. Journal of Hand Therapy. 2019. DOI: 10.1016/j.jht.2017.09.003

[15] Medical malpractice litigation following humeral fractures in the United States. Shoulder & Elbow. 2023. DOI: 10.1177/17585732231201976

[16] The association between seeking financial compensation and injury recovery following motor vehicle related orthopaedic trauma. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1152-2

[17] Psychological predictors of change in the number of musculoskeletal pain sites among Norwegian employees: a prospective study. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1503-7

[18] Systematic review: Predicting adverse psychological outcomes after hand trauma. Journal of Hand Therapy. 2017. DOI: 10.1016/j.jht.2016.11.006

[19] Örebro Musculoskeletal Pain Screening Questionnaire (scoring + interpretation). WorkCover. 2007.

[20] Burden Incurred by Patients and Their Caregivers After Outpatient Surgery: A Prospective Observational Study. Clinical Orthopaedics & Related Research. 2014. DOI: 10.1007/s11999-013-3270-6

[21] Responsiveness of the EQ-5D in breast cancer patients in their first year after treatment. Health and Quality of Life Outcomes. 2009. DOI: 10.1186/1477-7525-7-11

[22] Current Concepts Review - Hallux Rigidus and Osteoarthrosis of the First Metatarsophalangeal Joint. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199806000-00015

[25] Using a psychosocial subgroup assignment to predict sickness absence in a working population with neck and back pain. BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-81

[26] Can a back pain screening tool help classify patients with acute pain into risk levels for chronic pain?. European Journal of Pain. 2015. DOI: 10.1002/ejp.615

[27] The Use of Psychosocial Services Post Hand and Upper Limb Injury and Trauma: A Pilot Study. HAND. 2017. DOI: 10.1177/1558944717725373

[28] Symptoms of Posttraumatic Stress Disorder After Orthopaedic Trauma. The Journal of Bone and Joint Surgery-American Volume. 2004. DOI: 10.2106/00004623-200406000-00001

[29] A quality of life questionnaire for patients with scapula alata (SA-Q): development and validation. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03284-4

[32] Head_Computed_Tomography_Is_Not_Useful_for_Evaluating_Patients_Change_in_Mental_S0883540313009406. n.d..

[33] Coxa Vara in Childhood: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00003

[34] Arm Pain without Physical Findings: Medicine Vs the Law?. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2000.0517

[41] Comparison of the Musculoskeletal Function Assessment Questionnaire with the Short Form-36, the Western Ontario and McMaster Universities Osteoarthritis Index, and the Sickness Impact Profile Health-Status Measures. The Journal of Bone and Joint Surgery (American Volume)*. 1997. DOI: 10.2106/00004623-199709000-00006

[44] “Blue flags”, development of a short clinical questionnaire on work-related psychosocial risk factors - a validation study in primary care. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1677-z

[46] Minimizing the source of nociception and its concurrent effect on sensory hypersensitivity: An exploratory study in chronic whiplash patients. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-29

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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.