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关节囊松解

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Rehabilitation after arthroscopic capsular release for frozen shoulder — early in-hospital program and the outpatient phases that keep the range won at surgery.

Updated Jun 2026
图示展示一个人使用门框滑轮装置抬起一只手臂。
在肩关节囊松解术后恢复活动范围。 Kieran Hirpara 4.0

本页面由机器翻译，尚未经临床医生审核。英文版本为权威版本。

本方案涵盖基兰·希尔帕拉（Kieran Hirpara）医生在罗克汉普顿 Mater 私人医院进行的关节镜下关节囊松解术后的康复过程，包括住院期间及术后数周至数月的康复安排。请在首次物理治疗就诊时携带此页面或其 PDF 文件，以确保康复治疗的协调性。您的物理治疗师将根据您肩关节的活动情况，通过以下阶段为您个体化推进康复进程。

若对术后伤口有任何疑虑，请联系诊室。拍摄伤口照片并发送电子邮件供医生审阅通常会有所帮助。

预期情况

关节囊松解术是针对僵硬肩（冻结肩）的手术，这将彻底改变您的康复方式。大多数肩部手术旨在修复某些结构，如肌腱或撕裂的韧带，早期康复的重点是保护这些修复部位，因此您需要佩戴悬吊带，并将活动范围限制在特定限度内。而本手术则完全相反。手术中并未缝合任何需要保护的组织。外科医生已松解关节内紧绷且瘢痕化的关节囊，并在您麻醉状态下将肩关节活动至全范围，因此手术的效果即为获得活动度。从您苏醒的那一刻起，康复的任务就是保持这种活动度，以防肩关节再次僵硬。

这意味着没有保护期，也无需有所保留。您应立即开始活动肩关节，既包括主动活动，也包括利用健侧手臂辅助推动，并且每天多次在各个方向上持续增加活动范围。

您的锻炼涉及三种类型的活动，您的医疗团队将标明适用于您的类型：

  • 被动活动 指肩关节完全放松，由健侧手臂、拐杖或滑轮系统完成所有动作。
  • 主动辅助活动 指您利用健侧手臂或辅助器具的帮助，自行活动患侧手臂。
  • 主动活动 指您依靠自身肌肉力量活动手臂，无需任何辅助。

为何不使用吊带

关节囊松解术后无需使用吊带保护修复组织，且保持肩部静止反而不利于康复。若任其休息，松解后的肩部会再次变得僵硬。再僵硬化是该手术效果令人失望的主要原因，而通过早期且频繁的活动可很大程度上预防这一情况。

因此，与修复术不同，您无需在吊带中睡眠，也无需保持手臂静止，没有任何动作是禁忌的。从术后第一天起，即鼓励您自由活动手臂，并在各个方向上尽可能扩大活动范围，包括向外旋转手臂。仅提供简易吊带以提供短期舒适，并在外出时防止手臂受到碰撞；请尽可能少用吊带，切勿因使用吊带而让肩部保持静止。

关键点

  • 保持活动。 从一开始就使用手臂进行日常活动，如洗漱、穿衣和进食。活动可维持您在手术中获得的关节活动度。
  • 向各个方向增加活动度。 拉伸至出现明显不适感，而非剧烈疼痛，并在每个平面上将肩部活动至极限，包括手臂外旋。术后无需遵循“切勿超过此处”的限制。
  • 少量多次拉伸。 每天多次进行简短的家庭拉伸练习，优于单次长时间拉伸。两次拉伸之间关节会重新变僵硬，因此频率至关重要。
  • 控制疼痛以便活动。 在进行锻炼和物理治疗预约前服用止痛药。良好的疼痛控制是进行拉伸的前提。许多人发现拉伸前热敷、拉伸后冰敷有帮助。
  • 频繁进行物理治疗。 前六周内每周至少进行两次物理治疗。首次就诊时请携带本页内容。

手术时通常会在关节内注射类固醇，以减轻炎症并降低关节重新变僵硬的趋势。

住院期间——您的首次锻炼

物理治疗师将在医院为您进行检查，并在您出院前开始指导您进行以下锻炼。这些锻炼有助于保持手、肘和肩部的活动，并立即开始促进肩关节活动度的恢复。请在锻炼前服用止痛药，以便能够自由活动。请按照医疗团队的指示进行锻炼，并在家中继续坚持。

您的门诊康复

关节囊松解术后，康复进程与肌腱修复手术相反：无需保护，因此所有努力都集中于维持活动度。术后最初几周内肩关节最容易再次僵硬，因此物理治疗会立即开始，频率较高，并持续数月，直至您的活动度稳定。以下阶段遵循该手术已发表的康复方案模式（来源列于文末）。周数范围仅为典型值，而非固定值：您的物理治疗师将根据您肩关节的活动情况推进康复，而非依据日历。

概览：

  • 第一阶段 — 早期康复： 大约前两周
  • 第二阶段 — 维持和恢复活动度： 第 2 至 6 周
  • 第三阶段 — 强化训练： 第 6 至 12 周
  • 第四阶段 — 恢复全面活动： 第 12 周以后

大约三周时，肩关节高度以下的活动通常会更加舒适，大部分活动度已恢复，尽管手臂在过头活动时通常仍感不适。大约三个月时，大多数人发现症状已基本缓解，且改善通常持续六至九个月，有时长达一年。

第一阶段——早期康复（第0–2周）

前两周的目标很简单：不要丧失手术中获得的关节活动度。 您需在家继续进行医院的锻炼，每天多次，并增加将肩关节向各个方向拉伸至极限的拉伸动作。良好的疼痛控制是实现这一目标的关键，因此请在锻炼和物理治疗前按时服用止痛药，并在拉伸前热敷、拉伸后冰敷（如有帮助）。在日常生活中，如洗漱、穿衣和进食时，可正常使用患肢。将每次拉伸进行至出现明显不适感，而非剧烈疼痛，并请记住，无需刻意回避任何方向的活动。

进入下一阶段的条件是…… 您能够自信且独立地每天多次完成家庭锻炼计划，疼痛控制良好，能够拉伸至目标活动范围，并且维持了肩关节在手术中达到的活动度。

第二阶段 — 保持并恢复关节活动度（第2–6周）

本阶段继续进行频繁的理疗和每日多次进行的家庭拉伸训练，以确保手术中获得的活动度不丢失，并持续增加关节活动范围。您的锻炼从辅助性活动逐步过渡到主动在所有方向上活动手臂，理疗师可能会增加手法关节松动术以提供帮助。在各个平面（包括外旋）上，将关节活动度推至其最大极限。在日常活动中正常使用手臂进行轻度活动。

进入下一阶段的标准是…… 手术中获得的活动度得以保持或仍在改善，肩关节水平以下的活动感到舒适，且疼痛已减轻至足以开始轻柔的抗阻训练。

第三阶段——强化训练（第6–12周）

随着关节活动度趋于稳定，重点转向重建肩部力量。本阶段需继续进行每日拉伸，因为强化训练绝不能以牺牲来之不易的活动度为代价。抗阻训练从轻柔开始，使用弹力带和轻重量针对肩袖肌群和肩胛骨周围肌肉进行锻炼，采用低负荷、高重复次数的模式。日常活动应基本恢复正常，在物理治疗师的指导下，较轻的休闲活动通常也可在此阶段恢复。

进入下一阶段的准备条件为…… 您在各个方向上的活动均达到完全或接近完全，且无痛；同时，您能够完成强化训练而不会引发疼痛加剧或任何活动度丧失。

第四阶段——恢复全面活动（第12周起）

最终阶段是逐步恢复较重的体力工作、 overhead（过头）任务及运动。正式康复通常总共持续三至四个月，且肩关节在此之后仍会持续改善：大多数人会继续在六至九个月内，有时长达一年，持续获得舒适感和信心。建议坚持简短的拉伸练习，直到你的关节活动度无需正式锻炼即可自行维持。进展应始终以你的主观感受为指导，因此如果僵硬或疼痛开始复发，应对措施是减轻负荷并恢复活动度，而非让肩关节休息。

恢复活动

大多数人在4至6周内即可恢复正常日常活动及多种类型的工作，因为此处的康复关键在于维持关节活动度，而非等待组织愈合。随着力量逐渐恢复，较重体力劳动及 overhead 运动将在随后的数周至数月内逐步恢复。如果在任何阶段肩部再次出现僵硬，应将其视为加强拉伸的信号，并及时就诊物理治疗师，而非休息。

您的练习

术后康复方案

上述门诊阶段参考了已发表的关节镜关节囊松解术康复方案，恢复里程碑亦源自相同资料。周数范围为典型情况而非固定标准，您的持续康复由物理治疗师根据肩部功能恢复情况，在诊所指导下进行个体化管理。本页面与诊所的一般术后恢复建议配合使用：请参阅术后疼痛管理和伤口护理。关于手术本身及其治疗的疾病，请参阅关节囊松解术和冻结肩。

Reviewed by Dr Kieran Hirpara · 10 June 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

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

Evidence & references

Adhesive Capsulitis (Frozen Shoulder) — Non-operative Staged Management & Post-operative Rehabilitation (Capsular Release)

Topic scope: Both (A) non-operative staged management of primary/secondary adhesive capsulitis (freezing -> frozen -> thawing), including physiotherapy, intra-articular steroid and hydrodilatation; and (B) post-operative rehabilitation after arthroscopic capsular release (ACR).

Defining principle of surgical rehab here (the inversion): Unlike virtually every other shoulder operation -- where a repair (cuff, labrum, pec major, instability) must be protected with a sling and ROM is restricted to avoid disrupting healing tissue -- frozen-shoulder release rehab is the OPPOSITE: the goal is to prevent re-formation of the capsular contracture. So the protocol is immediate, aggressive ROM, usually NO sling, passive + active ROM starting the same day or day 1, with stretching to the end of the freshly gained range. Delay or immobilisation is the enemy (re-stiffening), not the protector. This is the single most important point distinguishing this protocol from the others in this audit.

A. NON-OPERATIVE STAGED MANAGEMENT

Natural history / staging (consensus, weak evidence -- descriptive, no RCT)

Frozen shoulder is self-limiting in most but typically lasts 12-18 months across 3 clinical stages (Reeves' classic model; staging boundaries overlap and are not sharply separable in practice -- flagged as weak/consensus evidence; the original Reeves model was a single prospective cohort of 49 patients, not an RCT) [Brigham SOC; Chan 2017; Reeves 1975 via Willmore 2020]:

Stage Name Typical duration Clinical picture Management emphasis
1 Freezing (painful/inflammatory) 2-9 months Diffuse constant pain, worse at night; progressive ROM loss in a capsular pattern (ER > ABD > flexion > IR); loss of passive ER with arm at side is the hallmark Pain control; intra-articular steroid; gentle ROM within pain limits -- do NOT force end-range while highly inflamed
2 Frozen (adhesive/stiff) 4-12 months Pain subsides to dull ache; stiffness dominant; marked functional loss Restore motion: stretching, joint mobilisation grades III-IV, hydrodilatation; consider surgery if recalcitrant
3 Thawing 6-9 months (Brigham) Gradual spontaneous return of motion Progressive ROM + strengthening; PT 2-3x/week

(Stage durations from Brigham Standard of Care 2010 and Chan 2017: freezing 2-9 mo, frozen 4-12 mo, thawing 6-9 mo.)

Stepped non-operative interventions

  1. Education / "supervised neglect" + analgesia -- many resolve with reassurance, activity modification and analgesia alone (Codman; Hsu 2011 review). Weak (cohort/expert).
  2. Physiotherapy -- pendulum, PROM/AAROM/AROM, capsular stretching, joint mobilisation (grades I-II early for pain, III-IV later for tissue extensibility), scapular/posture work. Brigham: PT 1-2x/week in early stages (mainly HEP instruction), 2-3x/week in thawing. PT is best supported as an adjunct to mobilisation/injection/distension, not as a stand-alone cure (Itoi 2016 Current Concepts; Kelley/McClure/Leggin JOSPT 2009 guidance). Moderate; intensity/timing debated. Intensity caveat: end-range/high-intensity stretching is appropriate in the frozen/thawing phase but can be counter-productive in the acutely inflamed freezing phase -- match intensity to irritability (Kelley 2009).
  3. Intra-articular corticosteroid (glenohumeral) -- superior to placebo and to physiotherapy for short-term (up to 4-12 weeks) pain and function; benefit wanes after ~3 months. Strong for short term (multiple RCTs; Koh 2016 systematic review of 10 RCTs; Cochrane Buchbinder shoulder injection review). BESS pathway: GH steroid recommended for short-term symptom control; long-term (>3 mo) benefit not demonstrated (Rupani/Gwilym BESS 2025). Earlier injection (freezing phase) is the rationale -- steroid targets the inflammatory component.
  4. Hydrodilatation (distension arthrography) -- distends/ruptures the contracted capsule with saline +/- steroid +/- LA. A controlled, image-guided alternative to surgery. RCT/meta-analytic evidence is mixed: generally produces a transient functional/ROM gain, with no clear superiority over IA steroid alone in several network meta-analyses (Wu 2017 SR/MA of RCTs; Lin 2018 network MA). Some evidence hydrodilatation + steroid > steroid alone in refractory cases (Lee 2017 RCT). Low rate of needing later surgery after distension arthrogram (Nicholson 2020). Moderate; conflicting.

B. POST-OPERATIVE REHABILITATION (the "immediate aggressive ROM" protocols)

Surgery is reserved for cases recalcitrant to >=3-6 months of adequate non-operative care (Struyf 2024; Mullen 2025).

Arthroscopic capsular release (ACR)

  • Controlled, direct-vision release of the contracted capsule (rotator interval, CHL, anterior +/- inferior +/- 360 degree capsulotomy; care re axillary nerve inferiorly). Allows graded release with a low risk of iatrogenic fracture or cuff tear (Kanbe 2018, n=255; Jerosch 2001 360 degree release). Achieves reliable gains in final forward elevation and may shorten recovery (most improved by ~4 months -- McAllister/CORR Insights 2025; Saade 2023 MA favoured ACR for AFE). A gentle, controlled manipulation is often performed as part of the arthroscopic release to confirm the gained range.

Consensus POST-OP phased timeline (applies after arthroscopic capsular release)

The hallmark is immediate motion, no protective sling, same-day/day-1 ROM to hold the range just won in theatre.

Phase Window Sling ROM Active ROM Strengthening Notes
0 -- Immediate Day 0-1 (same day) NO sling (or sling only briefly for comfort/analgesia, discarded fast) Full passive ROM immediately; PT-assisted forward flexion + ER begun day 1; +/- continuous passive motion (CPM); pendulums; patient does HEP several times/day AAROM/AROM started day 1 alongside PROM (no protected period) -- Intra-articular steroid often injected at time of release to damp post-op inflammatory re-stiffening
1 -- Early Week 0-2 None Aggressive PROM/AAROM to maintain gained range; stretch into end-range daily; hold ER/ABD/flexion Active motion continued Light scapular/rotator-cuff activation as pain allows Pain control critical to allow the patient to move -- adequate analgesia / interscalene block / oral steroid taper
2 -- Strengthening Week 2-6 None Continue to full ROM Full AROM goal Rotator cuff + scapular strengthening begins ~week 2 (Kanbe protocol) Most back to normal daily activity / work by 4-6 weeks
3 -- Return to function ~6 weeks-3 months None Maintain full ROM Full Progressive strengthening to full Recurrence of stiffness is the main failure mode -> continued HEP emphasised

Representative published protocol (Kanbe 2018, J Orthop Surg Res, n=255, ACR): "passive, assisted-active and stooping (pendulum) exercises for forward flexion and external rotation commenced 1 day after surgery... after 2 weeks of passive exercise, patients began active exercise to strengthen the rotator cuff and scapular stabilisers... after 4-6 weeks patients returned to normal work without limitation." Many ACR series add an intra-articular steroid + controlled manipulation at the index procedure (Filip Struyf 2024; PMC5137660).

Post-surgical physiotherapy is universally agreed to be essential but is under-standardised -- there is no high-level RCT defining the optimal post-release regimen; protocols are consensus/expert and vary widely (Willmore 2020 Shoulder & Elbow, "Post-surgical physiotherapy in frozen shoulder: a review"). Weak/consensus.

KEY CONTROVERSIES

  1. Evidence base for arthroscopic release. ACR gives a controlled, direct-vision release with a low iatrogenic fracture/cuff-tear risk and reliable gains in final elevation. Systematic reviews show consistently acceptable results, though there is no definitive RCT defining the optimal technique (Saade 2023 MA; McAllister 2025). Weak/moderate evidence (large cohorts).
  2. Steroid timing. Strong short-term benefit (<12 wk) but no durable >3-month benefit; debate over injecting early (freezing/inflammatory phase) vs reserving for refractory cases (Koh 2016; Rupani/Gwilym BESS 2025; Lin 2018).
  3. Aggressive vs gentle physiotherapy. High-intensity end-range stretching helps in the frozen/thawing phases but may worsen pain and prolong the condition if applied to the acutely inflamed freezing phase -- "intensity should match irritability" (Kelley/McClure 2009; Itoi 2016). Post-operatively, by contrast, aggressive immediate ROM is mandatory to prevent re-stiffening.
  4. Hydrodilatation worth it? Transient benefit only and not clearly better than IA steroid alone in pooled RCT data (Wu 2017; Lin 2018), though some refractory-case RCT support (Lee 2017) and a low rate of needing later surgery (Nicholson 2020).
  5. Does anything change the natural history? No intervention is proven to shorten the overall 12-18 month course in the highest-quality reviews; most accelerate symptom relief rather than alter end-point (Rookmoneea 2010 JBJS Br; Hsu 2011). Strong (negative).

EVIDENCE STRENGTH FLAGS (summary)

  • STRONG (RCT / SR-MA): IA corticosteroid short-term benefit (Koh 2016 SR of 10 RCTs; Cochrane); hydrodilatation = transient, not superior to steroid (Wu 2017 SR-MA of RCTs; Lin 2018 network MA).
  • MODERATE: end-range/scapular mobilisation (Yang 2012 RCT); ACR clinical outcomes (large cohorts -- Kanbe 2018 n=255; Jerosch 2001).
  • WEAK / CONSENSUS ONLY: 3-stage natural-history model & stage durations (Reeves cohort, descriptive); the post-operative rehab protocol itself (no defining RCT; expert/consensus -- Willmore 2020); optimal ACR technique (published series are heterogeneous).

CITATIONS

RAG corpus (180,000+ Orthopaedic articles)

  • Guyver P, Bruce D, Rees J. Frozen shoulder -- a stiff problem that requires a flexible approach. Maturitas. 2014.
  • Kim J, Gahlot N, Park HB. Frozen shoulder: a narrative review of current treatment concepts and the underlying scientific evidence. Clinics in Shoulder and Elbow. 2025;28(4).
  • Hsu JE, Anakwenze OA, Warrender WJ, et al. Current review of adhesive capsulitis. J Shoulder Elbow Surg. 2011;20(3):502-514.
  • Koh KH. Corticosteroid injection for adhesive capsulitis in primary care: a systematic review of randomised clinical trials. Singapore Med J. 2016.
  • Rupani N, Gwilym SE. British Elbow and Shoulder Society patient care pathway: Frozen shoulder. Shoulder & Elbow. 2025;17(4).
  • Sheridan MA, Hannafin JA. Upper Extremity: Emphasis on Frozen Shoulder. Orthop Clin North Am. 2006.
  • Chan H, Pua P, How C. Physical therapy in the management of frozen shoulder. Singapore Med J. 2017.
  • Willmore EG, Millar NL, van der Windt D. Post-surgical physiotherapy in frozen shoulder: a review. Shoulder & Elbow. 2020;14(4).
  • Lamplot JD, Lillegraven O, Brophy RH. Outcomes from conservative treatment of shoulder idiopathic adhesive capsulitis... Orthop J Sports Med. 2018.
  • Itoi E, Arce G, Bain GI, et al. Shoulder Stiffness: Current Concepts and Concerns. Arthroscopy. 2016;32(7).
  • Kanbe K. Clinical outcome of arthroscopic capsular release for frozen shoulder: essential technical points in 255 patients. J Orthop Surg Res. 2018;13(1). (post-op protocol: day-1 ROM, 4-6 wk RTW)
  • Jerosch J. 360 degree arthroscopic capsular release in patients with adhesive capsulitis... Knee Surg Sports Traumatol Arthrosc. 2001;9(3).
  • McAllister NB. CORR Insights: Releasing forces in adhesive capsulitis... Clin Orthop Relat Res. 2025.
  • Saade F, van Rooij F, Saffarini M, et al. Management of shoulder stiffness following rotator cuff repair: a systematic review and meta-analysis. JSES Rev Rep Tech. 2023.
  • Wu W, Chang K, Han D, et al. Effectiveness of glenohumeral joint dilatation for treatment of frozen shoulder: a systematic review and meta-analysis of RCTs. Sci Rep. 2017. (SR-MA of RCTs)
  • Lin M, Hsiao M, Tu Y, et al. Comparative efficacy of intra-articular steroid injection and distension... a systematic review and network meta-analysis. Arch Phys Med Rehabil. 2018. (network MA)
  • Lee D, Yoon S, Lee MY, et al. Capsule-preserving hydrodilatation with corticosteroid vs corticosteroid alone in refractory adhesive capsulitis: a randomized controlled trial. Arch Phys Med Rehabil. 2017. (RCT)
  • Nicholson JA, Slader B, Martindale A, et al. Distension arthrogram in the treatment of adhesive capsulitis has a low rate of repeat intervention. Bone Joint J. 2020;102-B(5).
  • Uppal HS. Frozen shoulder: a systematic review of therapeutic options. World J Orthop. 2015.
  • Mullen JP, Hauer TM, Lau EN, et al. Adhesive capsulitis of the shoulder. Arthroscopy. 2025;41(7).
  • Yang J, Jan M, Chang C, et al. Effectiveness of the end-range mobilization and scapular mobilization approach... a randomized control trial. Manual Therapy. 2012. (RCT)
  • Rookmoneea M, et al. The effectiveness of interventions in the management of patients with primary frozen shoulder. J Bone Joint Surg Br. 2010;92-B(9).
  • Struyf F. Frozen Shoulder. 2024 (surgical indication & post-op steroid + controlled manipulation).

Published rehab protocols (URLs)

  • Brigham & Women's Hospital -- Standard of Care: Shoulder Adhesive Capsulitis (Dept of Rehabilitation Services, 2010): https://www.brighamandwomens.org/assets/BWH/patients-and-families/rehabilitation-services/pdfs/shoulder-adhesive-capsulitis.pdf (source for the 12-18 mo / 3-stage durations, capsular pattern, PT frequency 1-2x/wk early & 2-3x/wk thawing, mobilisation grades, steroid 4-6 wk short-term benefit).
  • BESS (British Elbow & Shoulder Society) Frozen Shoulder patient care pathway -- Rupani & Gwilym, Shoulder & Elbow 2025 (GH steroid short-term only, no >3 mo benefit).
  • Kanbe 2018 ACR open-access (post-op day-1 ROM protocol): https://pmc.ncbi.nlm.nih.gov/articles/PMC5857121/
  • ChoosePT / APTA patient guide to frozen shoulder (lay phased overview): https://www.choosept.com/guide/physical-therapy-guide-frozen-shoulder-adhesive-capsulitis

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Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

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

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

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

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

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

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

5. Downstream recipients.

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

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

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

b. Other rights.

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

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

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

Section 3 -- License Conditions.

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

a. Attribution.

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

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

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

ii. a copyright notice;

iii. a notice that refers to this Public License;

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

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

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

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

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

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

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

Section 4 -- Sui Generis Database Rights.

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

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

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

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

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

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

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

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

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

Section 6 -- Term and Termination.

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

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

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

2. upon express reinstatement by the Licensor.

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

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

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

Section 7 -- Other Terms and Conditions.

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

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

Section 8 -- Interpretation.

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

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

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

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

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

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