Skip to content

Patients › Rehabilitation

全面关节镜管理（CAM）

PDF Evidence
一名游泳者正在划水，象征着重新恢复舒适的肩部过顶活动。
全面关节镜治疗后的康复旨在恢复舒适且功能性的肩关节活动。 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。

本方案涵盖在罗克汉普顿 Mater 私人医院由 Kieran Hirpara 医生进行综合关节镜管理（Comprehensive Arthroscopic Management, CAM）手术后的康复过程，包括住院期间及术后数周和数月的康复安排。请在您首次物理治疗就诊时携带此页面或其 PDF 版本，以确保您的康复计划协调一致。您的物理治疗师将根据您肩关节的活动情况及手术中的具体操作，按以下阶段个体化推进您的康复进程。

如果术后对伤口有任何疑虑，请联系诊室。拍摄伤口照片并通过电子邮件发送以供审查通常很有帮助。

预期情况

CAM 手术是一种针对磨损、患有关节炎的肩关节的微创（关节镜）手术。该手术并非进行关节置换，而是旨在清理关节并使其恢复活动，从而减轻疼痛：外科医生会磨平粗糙的软骨，移除游离碎片和骨刺，松解紧张的关节囊以使肩关节能够再次旋转，并松解关节前方的神经。其目标是为您争取多年更舒适、活动度更好的肩关节，并推迟或避免进行关节置换。

这种手术方式决定了您的康复过程。由于外科医生松解了紧张、僵硬的肩关节，并努力恢复您的旋转功能，术后最重要的任务是保持这种活动度：如果肩关节静止不动，它很可能会再次变得僵硬。但由于外科医生也处理了磨损的关节面，早期的活动是以循序渐进、受控的方式进行的：您需要早期且频繁地活动，但在进行拉伸时应循序渐进，而非强行拉伸，从而使关节平稳恢复而非引发炎症。因此，康复过程以活动为主导，类似于冻结肩松解术，但更为温和且渐进。

您的锻炼涉及三种类型的活动，您的医疗团队将标记适用于您的类型：

  • 被动活动 是指肩关节完全放松，由另一侧手臂、木棍或滑轮系统完成动作。
  • 辅助主动活动 是指您在另一侧手臂或物体的帮助下自行活动手臂。
  • 主动活动 是指您依靠自身力量活动手臂，无需辅助。

关于您的悬臂带

在最初的一到两周内，您通常会使用悬臂带来获得舒适感。悬臂带的作用是使手臂得到休息，并在关节稳定过程中防止其受到碰撞；它并不能维持修复结构的完整性。关键信息恰恰与肌腱或韧带修复相反：悬臂带仅用于提供舒适感，且肩部绝不能因长期固定而僵硬。 从第一天起就要从悬臂带中取出手臂进行锻炼，在舒适允许的范围内用手臂进行日常轻度活动，并在早期疼痛缓解后尽可能长时间地不使用悬臂带。

如果外科医生在手术中重新附着了您的肱二头肌肌腱（即肱二头肌肌腱固定术），医疗团队将要求您在愈合期间（约六周内）避免提举重物及肘部用力弯曲，并会告知您是否适用此限制。

要点

  • 保持活动。 从一开始就使用手臂进行轻度日常活动，如洗漱、穿衣和进食。轻柔、规律的活动是防止肩关节再次僵硬的关键。
  • 加强旋转训练。 手臂外旋（外旋）是本次手术恢复的主要动作之一，请反复进行此项练习。恢复并保持外旋功能是一个关键目标。
  • 循序渐进进行拉伸，切勿强行用力。 拉伸至有轻微牵拉感即可，而非剧烈疼痛。由于关节表面已接受手术处理，强行进行剧烈、疼痛的拉伸会导致肩关节炎症，从而延缓康复进程。少量多次优于长时间、用力的拉伸。
  • 控制疼痛以便能够活动。 在进行锻炼和物理治疗预约前服用止痛药。许多人发现拉伸前热敷、拉伸后冰敷有所帮助。
  • 定期接受物理治疗。 在前六周内坚持定期就诊。请将本页内容带给您的首次就诊医生。

住院期间——您的首次锻炼

物理治疗师将在医院为您进行评估，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，并立即开始恢复肩关节的活动范围。请在锻炼前服用止痛药，以便您能够舒适地进行活动。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

在CAM手术后，康复以运动为导向：肩关节此前僵硬，现已松解，因此早期的重点是在其再次变紧之前，以尊重已处理关节面的渐进方式，维持并重建关节活动度。物理治疗开始较早，保持规律，并持续数月。以下阶段遵循该手术已发表的康复方案模式（参考文献列于文末）。周数范围仅为典型参考，而非固定不变：您的物理治疗师将根据您肩关节的活动情况推进康复，而非依据日历时间。通常安排在术后约2周、6周以及3至4个月时进行门诊复查。

概览康复进程：

  • 第一阶段 — 早期活动：大约前两周
  • 第二阶段 — 恢复活动度：第2周至第6周
  • 第三阶段 — 力量训练：第6周至第12周
  • 第四阶段 — 恢复全面活动：第12周以后（约三个月后）

大多数人在最初一至三个月内即可感受到明显的疼痛缓解和活动改善，且功能改善通常会在六至十二个月内持续进展。

第一阶段——早期活动（第0–2周）

最初两周的目标是使肩关节活动起来，并保持手术中获得的关节活动度，同时避免刺激关节。您需在家中每天多次继续进行医院指导的锻炼：包括被动和主动辅助运动、钟摆运动，以及向各个方向的轻柔拉伸，包括手臂外旋。吊带仅用于舒适目的，在进行锻炼和轻度日常活动时请取下吊带。良好的疼痛控制是实现活动的前提，因此请在锻炼前按时服用止痛药，并根据需要，在锻炼前使用热敷、锻炼后使用冰敷。每个拉伸动作应轻柔至有轻微牵拉感，而非尖锐疼痛。

进入下一阶段的条件是…… 您能自信地每天多次完成家庭锻炼计划，疼痛逐渐缓解，且肩关节能自由地活动至早期活动范围。

第二阶段——恢复活动范围（第2–6周）

此阶段继续进行常规物理治疗和居家锻炼计划，在肩部允许的情况下进一步增加活动范围。您的锻炼从辅助运动逐渐过渡到在所有方向上主动活动手臂，您的物理治疗师可能会增加手法关节松动术，并继续恢复外旋活动。拉伸仍保持分级进行，比第一周力度稍大，但仍以轻柔渐进为主，避免强行拉伸。在此阶段，大多数人已脱离吊带，并在日常轻度活动中正常使用手臂。

进入下一阶段的条件是…… 您的活动范围持续改善，肩高以下的动作感到舒适，且疼痛已减轻到可以开始轻柔抗阻训练的程度。

第三阶段——强化训练（第6–12周）

随着活动范围的改善，重点转向重建力量。继续进行轻柔的拉伸，以防止丧失已努力恢复的活动度。在大约第6周开始进行轻度的抗阻训练，使用弹力带和轻重量针对肩袖和肩胛骨肌肉进行训练，采用低负荷和高重复次数。日常活动应基本恢复正常，在物理治疗师的指导下，较轻的娱乐活动通常在此阶段恢复。

进入下一阶段的条件是…… 您在各个方向上拥有完全或接近完全的活动度且无不适，并且能够进行强化训练而不会引发疼痛加剧。

第四阶段 — 恢复全面活动（第12周起）

从大约三个月开始进入最终阶段，逐步恢复较重的工作、过顶任务及运动，并进行更高级的力量训练。肩关节在此之后仍会持续改善：大多数人会在六到十二个月内继续获得舒适感和信心。进展应始终以您的感受为指导：如果出现僵硬或酸痛感加重，应适当退阶，恢复活动范围并使关节稳定，而不是强行推进。

恢复活动

大多数人在最初几周内，一旦感到舒适并脱离悬吊带，即可恢复办公桌工作和轻度日常活动。较重、体力要求较高的工作以及过头运动将在随后的数周至数月内逐步恢复，通常从大约三个月开始，随着力量逐渐恢复。任何肩部手术后恢复驾驶均遵循诊所的标准政策，而非本方案中的固定时间点：请参阅上肢手术后驾驶，并在复诊时与您的外科医生确认。

您的练习

术后康复阶段

上述门诊康复阶段改编自CAM手术的已发表康复方案，恢复里程碑亦源自相同文献。周数范围为典型情况而非固定值，您的后续康复由物理治疗师根据您的肩部恢复情况及手术具体操作内容，在诊所指导下进行个体化调整。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，请参阅全面关节镜治疗和肩关节骨关节炎。

Reviewed by Dr Kieran Hirpara · 17 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

Comprehensive Arthroscopic Management (CAM) of Glenohumeral Osteoarthritis — Post-operative Rehabilitation

Topic scope: Post-operative rehabilitation after the Comprehensive Arthroscopic Management (CAM) procedure — a joint-preserving arthroscopic treatment for advanced glenohumeral osteoarthritis in young, active patients who wish to avoid or defer arthroplasty.

Defining principle of CAM rehab (a hybrid): CAM is not a repair, so — like a capsular release for frozen shoulder — there is no healing construct to protect and the priority is to keep the motion that was restored at surgery, especially external rotation freed by the capsular release and axillary nerve neurolysis. BUT, unlike a pure capsular release, CAM also resurfaces and reshapes the articular surfaces themselves (chondroplasty, microfracture, humeral osteoplasty). So the rehab is motion-led but graded: early and frequent passive/active-assisted ROM, short sling for comfort only, stretching eased to end-range rather than forced — Millett's own protocol instructs the patient to "proceed with caution while stretching to avoid joint inflammation and pain." Re-stiffening is the failure mode to prevent; joint flare from over-aggressive forcing is the one to avoid.

A. THE PROCEDURE (what is being rehabilitated)

CAM is a systematic, inclusive arthroscopic approach to the multiple pathologies of early-to-advanced glenohumeral OA, described by Millett and colleagues. It bundles, in one sitting, as many of the following as the joint requires [Millett 2013; Millett EATS 2015]:

  • Debridement, chondroplasty, synovectomy and loose-body removal — smoothing frayed cartilage and clearing mechanical debris.
  • Capsular release — to restore range, particularly external rotation, lost to the arthritic contracture.
  • Inferior humeral osteoplasty — excision of the inferior humeral "goat's-beard" osteophyte that tethers the axillary nerve and blocks motion.
  • Axillary nerve neurolysis — freeing the nerve adjacent to that osteophyte (a defining CAM step; note a validated CAM variant deliberately omits axillary nerve release and subacromial decompression with satisfactory durable results [Mahmoud/KSSTA 2023]).
  • Subacromial decompression ± biceps tenodesis ± microfracture of focal chondral defects, where indicated.

Patient selection (drives prognosis, not the rehab itself): best results with > 2 mm of joint space and glenohumeral congruity without significant deformity; less joint space and abnormal posterior glenoid shape (Walch B2/C) predict early failure [Millett 2016 predictors]. Survivorship (freedom from arthroplasty): 76.9% at minimum 5 years, 63.2% at minimum 10 years in suitable candidates [Mitchell 2016; Spiegl/Horan 2020].

B. POST-OPERATIVE PHASED TIMELINE

The published protocol is a 3-phase, individually-tailored program (Millett group; mirrored in clinic patient materials). Mapped here onto the practice's standard 4-phase patient structure. Clinic follow-up at 2 weeks, 6 weeks, and 3–4 months.

Phase Window Sling ROM Strengthening Notes
I — Early motion Week 0–2 Comfort only, ~1–2 wk, off for exercise from day 0 Passive + active-assisted ROM immediately; pendulums; gentle stretch in all planes incl. external rotation; caution — ease to end-range, do not force Hand/elbow/scapular setting only Goal: maintain the motion gained at surgery + prevent scar/re-contracture; pain control to permit motion
II — Restoring range Week 2–6 Off Progress AAROM → AROM all planes; keep working external rotation; add joint mobilisation; stretching graded (firmer, still not forced) Light scapular/cuff activation as pain allows Most back to light daily activity/work by this window
III — Strengthening Week 6–12 Off Maintain full/near-full ROM Elastic-resistance + light-weight cuff & scapular strengthening from ~6 wk, low load / higher reps; continued stretching Lighter recreation resumes
IV — Return to function/sport ~3 months + Off Full Advanced strengthening; graduated return to sport/heavy work Outcomes continue to improve over 6–12 months

Procedure-specific modifiers (surgeon-dependent): - Biceps tenodesis performed → avoid resisted elbow flexion / lifting ~6 weeks. - Microfracture of a focal chondral defect → early passive motion is beneficial for the marrow-stimulation clot (as in knee microfracture), but avoid heavy axial loading in the early weeks; favour motion over load. - Axillary nerve neurolysis performed → prioritise early external-rotation ROM to hold the gain; transient axillary nerve paraesthesia is recognised and usually settles.

Recovery milestones (from CAM outcome series, not a rehab trial): meaningful pain/function improvement within the first 1–3 months; sustained patient-reported improvement and satisfaction by 6–12 months [Outcomes/Survivorship series].

C. KEY CONTROVERSIES / EVIDENCE QUALITY

  1. No rehabilitation RCT exists for CAM. The post-operative regimen is expert/consensus from the originating group (Millett), not a tested protocol. Intensity and timing are reasoned from the procedure's components, not from comparative data. Weak/consensus.
  2. The evidence base for the operation is itself debated. CAM outcome series are predominantly Level IV (case series from a small number of high-volume centres); systematic reviews conclude arthroscopic debridement for GHOA lacks high-quality evidence for routine use, and isolated debridement + capsular release "may not provide substantial benefit" in most patients [Kelly 2014; van der Bracht 2013 critical review]. CAM's value is strongest in carefully selected young, high-demand patients with preserved joint space.
  3. Motion vs protection balance. The capsular-release component argues for aggressive early motion (re-stiffening is the enemy); the cartilage/microfracture/osteoplasty components argue for graded loading (joint flare is the enemy). The published protocol resolves this as early but cautious motion — the central rehab judgement.
  4. CAM is a family of procedures, not one operation. Exactly which steps were done (axillary nerve release, microfracture, biceps tenodesis) legitimately shifts the rehab — hence the per-patient modifiers above. A validated variant omits axillary nerve release/SAD entirely [Mahmoud 2023].

D. EVIDENCE STRENGTH FLAGS (summary)

  • MODERATE (large/long-term cohorts): CAM mid- and long-term survivorship + PRO improvement (Mitchell 2016 n-series, 76.9% @5 yr; Spiegl/Horan 2020, 63.2% @10 yr); preoperative predictors of failure (Morrison/Millett 2016).
  • WEAK / CONSENSUS ONLY: the post-operative rehabilitation protocol itself (no defining RCT; expert protocol from the originating group); debridement-based arthroscopy for GHOA (systematic reviews: low-quality evidence, Kelly 2014; van der Bracht 2013).
  • EXTRAPOLATED: early-motion rationale borrowed from arthroscopic capsular-release rehab; microfracture early-motion / load-caution rationale borrowed from marrow-stimulation cartilage literature.

CITATIONS

RAG corpus (180,000+ Orthopaedic articles) — CAM clinical evidence base

  • Millett PJ, Gobezie R, Boykin RE. Comprehensive Arthroscopic Management (CAM) procedure for treatment of glenohumeral osteoarthritis. Arthroscopy Techniques. 2015. (technique + post-op rehab description) DOI: 10.1016/j.eats.2015.04.003
  • Millett PJ, et al. Comprehensive Arthroscopic Management (CAM) Procedure: clinical results of a joint-preserving arthroscopic treatment for young, active patients with advanced shoulder osteoarthritis. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2012.10.028
  • Mitchell JJ, et al. Survivorship and patient-reported outcomes after CAM of glenohumeral osteoarthritis (minimum 5 years; 76.9% survivorship). Am J Sports Med. 2016. DOI: 10.1177/0363546516656372
  • Morrison/Millett, et al. CAM of glenohumeral osteoarthritis: preoperative factors predictive of treatment failure. Am J Sports Med. 2016. DOI: 10.1177/0363546516668823
  • Survivorship and PROs after CAM, minimum 10-year follow-up (63.2% survivorship). Am J Sports Med. 2020. DOI: 10.1177/0363546520962756 / OJSM 2021. DOI: 10.1177/2325967121s00213
  • Comprehensive arthroscopic management without axillary nerve release or subacromial decompression — satisfactory durable results in young patients. Knee Surg Sports Traumatol Arthrosc. 2023. DOI: 10.1007/s00167-023-07377-0
  • Arthroscopic Management of Glenohumeral Arthritis: a joint-preservation approach. JAAOS. 2018. DOI: 10.5435/jaaos-d-17-00214
  • Outcomes and survivorship after arthroscopic treatment of glenohumeral arthritis: a systematic review (ROM + PRO improvement, minimal complications). Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.02.036
  • Kelly EW, et al. Arthroscopic debridement and capsular release for the treatment of shoulder osteoarthritis (may not justify routine use). Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.08.025
  • van der Bracht H, et al. What is the role of arthroscopic debridement for glenohumeral arthritis? A critical examination of the literature (lacks high-quality evidence). Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.02.022
  • CAM vs total shoulder arthroplasty and hemiarthroplasty in patients < 50 years. EFORT Open Reviews. 2026. DOI: 10.1530/eor-2023-0156

Published rehab protocol (URLs)

  • Dr Peter Millett — Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis (procedure + components incl. inferior humeral osteoplasty, axillary nerve neurolysis, biceps tenodesis, microfracture): https://drmillett.com/wp-content/uploads/2017/02/comprehensive-arthroscopic-management-glenohumeral-osteoarthritis.pdf
  • The Upper Limb Clinic — Comprehensive Arthroscopic Management (3-phase rehab description: sling few weeks; Phase 1 passive/active-assisted ROM + cautious stretching; Phase 2 strengthening ~6 wk; Phase 3 advanced/return-to-sport ~3 mo; follow-up 2 wk / 6 wk / 3–4 mo): https://theupperlimbclinic.co.uk/comprehensive-arthroscopic-management-a-joint-preserving-solution-for-shoulder-arthritis/
  • Millett PJ, et al. CAM clinical results (open journal record): https://www.arthroscopyjournal.org/article/S0749-8063(12)01801-4/fulltext
  • CAM (EATS technique record, PubMed): https://pubmed.ncbi.nlm.nih.gov/26697301/

Note on the rehab evidence: there is no CAM-specific rehabilitation trial in the corpus or the literature. The phased protocol above is the originating group's expert protocol (Millett, mirrored in clinic patient materials), with the early-motion and load-caution rationale extrapolated from arthroscopic-capsular-release and cartilage marrow-stimulation rehab respectively. Treat phase timings as typical, surgeon-adjustable defaults — not as trial-derived prescriptions.

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

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.

Creative Commons may be contacted at creativecommons.org.