J Bone Joint Surg Am 2010; 92: 2767 – 75. J Bone Joint Surg Am. 2014; 45:1782–1790. Use crutches or a LSAchilles!Tendon!Rehab!Protocol!13/3/16! doi: 10.1016/j.injury.2014.06.022. Initially a walking boot is used for the first 4–5 weeks. A defect or gap in the Achilles tendon can usually be felt. 37,44 Additionally, studies suggest that LIPUS must be administered early after the time of tendon injury to achieve maximal benefit. Br J Sports Med. Title: ACFrOgAqkNZorXjmQNDZ-KF_VOa5PwWCDQrYiPV...xHxeKKEnKt_1JGskF6rdj-Aefw6pLMfALyzYA= Author: Melvin Created Date: 12/10/2015 8:44:24 PM Rehabilitation following Achilles tendon repair is vital in regaining motion, strength and function. OJSM 2016 2. 9. Wang KC, Cotter EJ, et al. Achilles Tendon Rupture Rehab Protocol 1-2 Weeks Splint in ankle plantar-flexion approximately 20 degrees Non-weight bearing with crutches 2-6 Weeks. thirteen group stockton; zillow bellevue idaho; waterford ponds ice fishing Alternar menú. The recovery after Achilles tendon rupture: a protocol for a multicenter prospective cohort study. After open repair, early functional rehabilitation improves outcome, but there are risks of infection and poor wound healing. Evidence-based accelerated rehabilitation protocol following operative repair of acute Achilles tendon ruptures; DF: dorsiflexion, PF: plantar flexion, ROM: range of motion. ACHILLES TENDON RUPTURE Accelerated Functional Rehabilitation Protocol 0 – 2 WEEKS Aircast boot with 2 cm heel lift NWB with crutches 2 – 6 WEEKS Aircast boot with 2 cm heel lift Protected weight-bearing with crutches as required Active plantar and dorsi flexion to neutral, inversion /eversion below neutral It is recommended that clinicians collaborate Zellers JA, Carmont MR, et al. ; The main causes of the rupture can be: overstretching of the heel during … Achilles tendon rupture accounts for 20% of all large tendon ruptures. of the Achilles tear and repair. 1998;26(6):789-93. Allow dorsiflexion to return naturally. The recovery after Achilles tendon rupture: a protocol for a multicenter prospective cohort study. ! 50:1325-1332. Purpose: Surgical repair after acute Achilles tendon rupture leads to lower re-rupture rates than non-surgical treatment. management of Achilles tendon ruptures. Rehabilitation Protocol 0-2 Weeks Post-Op a. 50:1325-1332. Accelerated Rehabilitation 8-week protocol Introduction Procedure: Conservative Management of Tendo-Achilles Rupture – Accelerated 8- week protocol ... Achilles Tendon Ruptures: A Meta-Analysis of Randomised Controlled Trials J Bone Joint Surg (Am) Boston: Vol … 1990 Mar;18(2):188-95. Consider taking a more conservative approach to range of motion, weight bearing, and rehab progression with tendon augmentation, re-rupture after non-surgical management, revision, chronic tendinosis, and co-morbidities, for example, obesity, older age, and steroid use. This study is a prospective randomized controlled clinical study. Rehabilitation and return to play following achilles tendon repair. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Coursework Hero will take good care of your essays and research papers, while you’re enjoying your day. Exercise bike with boot on. After the Achilles tendon rupture repaired , patients were randomly divided into 2 groups, and the rehabilitation protocol was traditional rehabilitation protocol and accelerated rehabilitation protocol under ultrasonic monitoring , respectively, to study the difference in efficacy between the groups. Your surgeon and you will determine what is best for you by discussing your specific injury and goals. ... accelerated functional rehabilitation. Operative Techniques in Sports Medicine. However, the pain subsides quickly. This rehabilitation used scar mobilization and friction massage) to decrease fibrosis. ... accelerated functional rehabilitation. 2017. A systematic review of early rehabilitation methods following a rupture of the Achilles tendon. The most common complication of Achilles tendinitis is pain, which may take at least 2 to 3 months to go away completely. Background: The aim of this study was to assess the effectiveness of 38 supervised postoperative physiotherapy (SVPh) visits conducted between 1 and 20 weeks after SSATOM on the values of 3D gait parameters measured at 10 and 20 weeks after surgery. Continue resisted inversion and eversion through range. Non weight bearing to the operative side for 2 weeks from the date of surgery. JBJS Am. scar mobilization and friction massage) to decrease fibrosis. The optimal postoperative rehabilitation protocol after surgical repair of an Achilles tendon rupture is evolving from the classic routine using rigid immobilization in a below-knee nonweightbearing cast for 6 weeks with subsequent ankle range of motion (ROM) and strengthening exercises. management of Achilles tendon ruptures. People who rupture their Achilles tendon generally are back walking—whether they have surgery or don’t have surgery—in about three months. But usually the muscle hasn’t recovered enough strength to get back to jogging until around six months, sometimes even longer. Achilles Accelerated Functional Rehab Protocol Mr. Andrej Nikoloski MBBS FRACS(Ortho) FAOrthA Orthopaedic Foot and Ankle Surgeon Kevin Willits, Annunziato Amendola et al. Professional academic writers. Achilles Tendon Repair Rehabilitation Protocol Timeframes for rehabilitation phases are a guide only and should be adapted to each individual patient’s progress, surgeon’s orders and with preference to err on the side of caution. The Achilles Tendon is the strong fibrous band that attaches the calf muscles to the calcaneus bone.. A rupture of the Achilles Tendon (ATR) is a common pathology being the most commonly ruptured tendon in the human body. Continue active resisted theraband exercises; plantarflex through full range, dorsiflexion to a natural plantigrade position, push no further. Minimal invasive surgery reduces these risks; however, there are concerns about its stability. 12) The estimated incidence ranges from 11 to 37 per 100,000 population. 16) In a 2012 meta-analysis by Soroceanu et al., 10) the mean age at the time of injury among 826 patients with an acute … contains some random words for machine learning natural language processing Operative Techniques in Sports Medicine. Regular soft tissue treatments (i.e. ... Polzer H. Accelerated rehabilitation following Achilles tendon repair after acute rupture - development of an evidence-based treatment protocol. Percutaneous and open surgical repairs of Achilles tendon ruptures: a comparative study. Mr Luke Spencer MBBS, FRACS(Orth) Luke@ballaratorthopaedics.com.au Rooms: (03) 5332 2969 !! Achilles Rupture Non-operative Protocol Page 3 of 3 Last Updated September 3, 2020 REFERENCES: 1. 2010 Dec 1; 92(17): 276-75. REHABILITATION GUIDELINES FOR ACHILLES TENDON REPAIR ACCELERATED PROTOCOL PHASE I (0-2 WEEKS) DATES: Appointments Begin physical therapy 14-16 days after surgery Rehabilitation Goals Protection of the surgically repaired tendon Wound healing Precautions In splint applied by MD postoperatively TTWB X 2 weeks using the axillary crutches how many people have $3,000,000 in savings; st neots police incident today; death notices in asheville, nc. 25:214-219. [Google Scholar] 23. Strengthening. 16) In a 2012 meta-analysis by Soroceanu et al., 10) the mean age at the time of injury among 826 patients with an acute … Enter the email address you signed up with and we'll email you a reset link. A defect or gap in the Achilles tendon ean usually be felt. Achilles tendon rupture, March 2018 2 Patient information – Achilles tendon rupture the foot is suddenly forced into an upward poi nting position (dorsiflexion). ... ACHILLES TENDON RUPTURE Accelerated Functional Rehabilitation Protocol 0 2 WEEKS Aircast boot with 2 cm heel lift NWB with crutches. 2016. Posted at 09:52h in jeffress funeral home south boston, virginia obituaries by warehouse jobs new jersey. Zellers JA, Carmont MR, et al. It mainly affects males between 30-40 years old 2. 3. Methods: Patients were randomized to operative or nonoperative treatment for acute Achilles tendon rupture. • Must be a complete, mid-substance Achilles tendon rupture & not a tendon avulsion from the calcaneus or gastroc/soleus. Browse our listings to find jobs in Germany for expats, including jobs for English speakers or those in your native language. Your surgeon and you will determine what is best for you by discussing your specific injury and goals. Material: Group I comprised male patients (n = 22) after SSATOM (SVPh x = 38 visits) and Group II comprised … The soleus is the biggest force contributor to the Achilles tendon [17] and contributes more than half of the vertical support of the centre of mass during running [18].It produces the largest muscle force during early acceleration, and the timing of soleus peak activation differs from that of the gastrocnemii [18]. Wang KC, Cotter EJ, et al. JBJS Am. Am J Sports Med. mushroom teether recall; 1600 westar drive oxnard, ca 93033; pappadeaux gift card walgreens does not return to normal until 6-7 weeks post-operatively, and thus it is not recommended to drive until that time frame. Achilles tendinopathy has a detrimental effect on physical and mental well-being. ↑ Brumann M, Baumbach SF, Mutschler W, Polzer H. Accelerated rehabilitation following Achilles tendon repair after acute rupture–development of an evidence-based treatment protocol. When the Achilles tendon ruptures, the person often hears a "pop" or "snap" at the time of injury and feels a sudden pain in the region of the Achilles tendon. acdf physical therapy protocol Published: June 8, 2022 Categorized as: chances of a bullet not firing The Gundersen Health System Rehabilitation Programs are evidence-based and soft tissue healing dependent programs designed to allow patients to progress to vocational and sport-related activities as quickly and safely as possible. Title: ACFrOgAqkNZorXjmQNDZ-KF_VOa5PwWCDQrYiPV...xHxeKKEnKt_1JGskF6rdj-Aefw6pLMfALyzYA= Author: Melvin Created Date: 12/10/2015 8:44:24 PM 1990 Mar;18(2):188-95. The optimal postoperative rehabilitation protocol after sur-gical repair of an Achilles tendon rupture is unknown. We would like to show you a description here but the site won’t allow us. Initially a walking boot is used for the first 4–5 weeks. Sometimes the Achilles tendon is weak, making it more prone to rupture. Consider taking a more conservative approach to range of motion, weight bearing, and rehab progression with tendon augmentation, re-rupture after non-surgical management, revision, chronic tendinosis, and co-morbidities, for example, obesity, older age, and steroid use. Brumann, M., Baumbach, S. F., Mutschler, W., & Polzer, H. (2014). An icon used to represent a menu that can be toggled by interacting with this icon. Strengthening. substancial - Free ebook download as Text File (.txt), PDF File (.pdf) or read book online for free. EPIDEMIOLOGY. This protocol was updated and reviewed by Dr. Devries and Dr. Scharer of BayCare Foot & Ankle Center and by Jessica Sigl, DPT on ... Operative versus non-operative treatment of acute Achilles tendon ruptures: a multi-center randomized trial using accelerated functional rehabilitation. • Must be a complete, mid-substance Achilles tendon rupture & not a tendon avulsion from the calcaneus or gastroc/soleus. Injury. Phone: 574.247.9441 Fax: 574.247.9442 www.sbortho.com Achilles Rupture Non-operative Protocol Page 2 of 3 Last Updated September 3, 2020 - Inititiate toe-raising exercises using the unaffected leg to support injured leg Begin standing calf stretch at 5 weeks (knee flexed and extended) Continue eversion, inversion and plantar flexion isometrics with resistance bands. EPIDEMIOLOGY. There is sudden pain in the region ofthe Achilles tendon that subsides quickly. postop. Unlike muscle tissue, tendons don’t get a significant supply of blood. Blood delivers fluid and nutrients that are essential for healing. The less blood delivered, the longer it takes for tissue to heal. Add to that the sheer size of the Achilles tendon, and you’re in for a lengthy recovery. Muscle Injury Biology. 2010:92:2767-2775. 2010:92:2767-2775. It is now up to a rate of 37 out of 100,000 US citizens 1. With in-depth features, Expatica brings the international community closer together. 13,14,15) Men are 2 to 12 times more prone to Achilles tendon rupture than women. A must-read for English-speaking expatriates and internationals across Europe, Expatica provides a tailored local news service and essential information on living, working, and moving to your country of choice. Expatica is the international community’s online home away from home. There is weakness when trying to stand on tip-toes. peroneal tendonitis physical therapy protocol 08 Jun. The best approach varies for each individual. in surgical group, after injury in nonop. postop. Achilles Tendon Repair Post-op Rehabilitation Protocol . However, the pain subsides quickly. Westin et al. Allow dorsiflexion to return naturally. TreatmentNonsurgical treatment. Nonoperative treatment avoids the risks associated with surgery, such as infection. ...Surgery. The procedure generally involves making an incision in the back of your lower leg and stitching the torn tendon together.Rehabilitation. ... June 7, 2022 Wilkins R, Bisson Lj. The use of early functional rehabilitation in the treatment of nonoperative Achilles tendon ruptures has been shown to provide patients with outcomes similar to operative treatments. Continue resisted inversion and eversion through range. 2010;38:2186-93 1 Achilles Tendon Rupture Rehabilitation Protocol Phase 1- Weeks 1-2: Physiotherapy goals: • Maintain independent ambulation Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play. American Academy of Orthopaedic Surgeon, 18(8), 503-510. DIAGNOSTIC IMAGING doi: 10.1016/j.injury.2014.06.022. Exercise bike with boot on. Rehabilitation Protocol: Achilles Tendon Rupture Repair Department of Orthopaedic Surgery Lahey Hospital & Medical Center, Burlington 781-744-8650 Lahey Outpatient Center, Lexington 781-372-7020 ... your physical therapy consult for 8 weeks after your surgery. Achilles tendon rupture accounts for 20% of all large tendon ruptures. An Achilles rupture is fairly common, and unfortunately increasing in occurrence over the last few years. ' '' ''' - -- --- ---- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- ----- Brumann, M., Baumbach, S. F., Mutschler, W., & Polzer, H. Accelerated rehabilitation following Achilles tendon repair after acute rupture-Development of an evidence-based treatment protocol. 13,14,15) Men are 2 to 12 times more prone to Achilles tendon rupture than women. [Google Scholar] 23. Muscle healing is characterised by a reparative process that involves formation of a scar ().The scar tissue formation has been observed from 6 weeks until 23 months after the injury.Skeletal muscle healing is divided into three phases: destruction, repair and remodelling ().The destruction phase involves myofibres rupture and necrosis, haematoma … This protocol was updated and reviewed by Dr. Devries and Dr. Scharer of BayCare Foot & Ankle Center and by Jessica Sigl, DPT on ... Operative versus non-operative treatment of acute Achilles tendon ruptures: a multi-center randomized trial using accelerated functional rehabilitation. Injury; 45(11): 1782-1790 • Hutchison, A.M., Topliss, C., Beard, D., Evans, R.M & Williams, P. The treatment of a rupture of the Achilles Tendon using a dedicated management programme. Accelerated rehabilitation following Achilles tendon repair after acute rupture – Development of an evidence-based treatment protocol. We would like to show you a description here but the site won’t allow us. Br J Sports Med. The primary outcome was the rerupture rate as demonstrated by a positive Thompson squeeze test, the presence of a The American journal of sports medicine. 25:214-219. Passive dorsiflexion both with knee in extension and flexed to 35 – 400 until gentle stretch on achilles. 12) The estimated incidence ranges from 11 to 37 per 100,000 population. DIAGNOSTIC IMAGING Minimal invasive surgery reduces these risks; however, there are concerns about its stability. group 2-4 weeks Aircast walking boot with 2-cm heel lift*† Protected weight-bearing with crutches This might be as soon as 2 to 3 weeks or as long 6 weeks after your injury. With the help of physical therapy, most people will return to normal activity in 4 to 6 months. In therapy, you may learn exercises to make your calf muscles stronger and your Achilles tendon more versatile. ... ACHILLES TENDON RUPTURE Accelerated Functional Rehabilitation Protocol 0 2 WEEKS Aircast boot with 2 cm heel lift NWB with crutches. The plantaris tendon Achilles tendon rupture without tendinopathy was chosen was transected, preventing a splinting phenomenon. Surprisingly, the Achilles tendon is the strongest tendon in the body, but it’s the most commonly torn one in the lower extremity. Seated heel raises. Accelerated Rehabilitation Program For Non –Operative Treatment of Achilles Tendon Ruptures1. 1.1. in surgical group, after injury in nonop. 10. Operative vesus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomised Trial Using Accelerated Functional Rehabilitation. peroneal tendonitis physical therapy protocol. Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to assess dynamic Injury. Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play. Achilles Tendon Rupture Rehab Protocol 1-2 Weeks Splint in ankle plantar-flexion approximately 20 degrees Non-weight bearing with crutches 2-6 Weeks. All pa-tients underwent an accelerated rehabilitation protocol that featured early weight-bearing and early range of motion. II. Lantto et al. TABLE E-1 Achilles Tendon Rupture Rehabilitation Protocol Time Frame Activity 0-2 weeks Posterior slab/splint; non-weight-bearing with crutches: immed. There is weakness when trying to stand on tip-toes. The best approach varies for each individual. Rehabilitation and return to play following achilles tendon repair. Do not stretch into pain. bearing progression with crutches and physical therapy at 4 weeks (see Appendix). J Bone Joint Surg Am 2010; 92: 2767 – 75. Purpose: Surgical repair after acute Achilles tendon rupture leads to lower re-rupture rates than non-surgical treatment. Percutaneous and open surgical repairs of Achilles tendon ruptures: a comparative study. After open repair, early functional rehabilitation improves outcome, but there are risks of infection and poor wound healing. Acute Ultrasonographic Investigation to Predict Rerupture and Outcomes in Patients with an Achilles Tendon Rupture. *Based on Nilsson-Helander K et al. 2017. Al-though a 6-week cast immobilization is common, many early functional rehabilitation protocols have been implemented. Proprioceptive rehabilitation. There are numerous protocols for post achilles tendon rupture rehabilitation. Avoid forceful active and passive range of motion of the Achilles for 10 - 12 weeks. This protocol provides you with general guidelines for initial stage and progression of rehabilitation according to specified time frames, related tissue tolerance and directional preference of movement. Repeat 3 x 30 seconds The American journal of sports medicine. Our global writing staff includes experienced ENL & ESL academic writers in a variety of disciplines. peroneal tendonitis physical therapy protocol. AAOS Clinical Practice Guideline: Diagnosis and Treatment of Acute Achilles Tendon Rupture. TABLE E-1 Achilles Tendon Rupture Rehabilitation Protocol Time Frame Activity 0-2 weeks Posterior slab/splint; non-weight-bearing with crutches: immed. 1. This rehabilitation used 3. Pull back until you feel a stretch. 2005;26(5):412-5. Specific changes in the program will be made by the 2014; 45:1782–1790. group 2-4 weeks Aircast walking boot with 2-cm heel lift*† Protected weight-bearing with crutches The common denominator is that most newer studies are finding that faster early mobilization protocols result in fewer re-ruptures and better healing compared to older more conservative protocols. Foot Ankle Int. Injury. LIPUS treatment accelerated healing in the rat MCL injury model at 2 weeks after healing, but not at longer time points. The purpose of this study was to conduct a meta-analysis to of the Achilles tear and repair. This could be due to specific medical conditions e.g. Active ankle eversion/inversion. May also be used for Operative Treatment of Achilles Tendon Ruptures July 2013 Updated Version Prepared and Modified by: Daniela Rubinger, BScPT, Citadel Physiotherapy Mark Glazebrook MSc. after right sided Achilles tendon repair . 2016. Rehabilitation following Achilles tendon repair is vital in regaining motion, strength and function. Achilles Accelerated Functional Rehab Protocol Mr. Andrej Nikoloski MBBS FRACS(Ortho) FAOrthA Orthopaedic Foot and Ankle Surgeon Kevin Willits, Annunziato Amendola et al. When the Achilles tendon ruptures, the person often hears a "pop" at the back ofthe lower leg. PhD MD FRCS(C) 0-2 weeks Simply kick back and relax. Password requirements: 6 to 30 characters long; ASCII characters only (characters found on a standard US keyboard); must contain at least 4 different symbols; Rupture ofthe tendon causes weakness when trying to stand on tiptoes. 2010 Dec 1; 92(17): 276-75. Operative vesus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomised Trial Using Accelerated Functional Rehabilitation. ! Continue active resisted theraband exercises; plantarflex through full range, dorsiflexion to a natural plantigrade position, push no further. ↑ Brumann M, Baumbach SF, Mutschler W, Polzer H. Accelerated rehabilitation following Achilles tendon repair after acute rupture–development of an evidence-based treatment protocol. This lets us find the most appropriate writer for any type of assignment. 2 Small prospective human clinical trials 13,17,18 used early functional … J Bone Joint Surg Am. Achilles Tendon Rupture (Nonsurgical) – Rehabilitation Guidelines Derek Plausinis, MASc, MD, FRCS(C) _____ 0 to 2 Weeks Post-injury • No weight bearing • Splint, no ankle motion exercises 2 to 4 Weeks • ‘Touch’ weight bearing, crutches • Walker boot full time except for exercises: ... • Continue ‘2 to 4 week’ protocol Carefully monitor the tendon and incisions for mobility and signs of scar tissue formation. Non-Operative Treatment of Achilles Tendon Rupture Post-Operative Protocol Accelerated Rehabilitation Program: Weeks 1-2: • Short leg fiberglass cast with ankle in plantarflexion of ~20 degrees • Non-weight bearing with crutches for ambulation assistance Weeks 2-6: • Transition to CAM walking boot with 6 heel lifts • For patients with re-rupture repairs, comorbidities such as diabetes, osteoporosis or high body mass index (BMI), healing times and weight bearing (WB) progressions may be delayed. Avoid forceful active and passive range of motion of the Achilles for 10 - 12 weeks. what is accelerated rate of extinction; vector lighters review; brownsville inmate list 2020; castelul din carpati idei principale. When the Achilles tendon ruptures, the person often hears a "pop" or "snap" at the time of injury and feels a sudden pain in the region of the Achilles tendon. Wilkins R, Bisson Lj. ... Polzer H. Accelerated rehabilitation following Achilles tendon repair after acute rupture - development of an evidence-based treatment protocol. Achilles Tendon Repair | ORTH03.03B | A/Prof Andrew Bucknill – Head of Unit, Department of Orthopaedic Surgery | Last updated October 2020 11 Non-Weight-bearing Achilles / Calf Stretch - Sit with a Theraband around the ball of your foot . Video 4. single leg calf eccentric with smith machine Seated calf isometric test. • If surgeon uses plantarflexion wedges, remove as per their recommendations. 2014 2. of acute achilles tendon rupture. Am J Sports Med. Accelerated Rehabilitation 8-week protocol Introduction Procedure: Conservative Management of Tendo-Achilles Rupture – Accelerated 8- week protocol ... Achilles Tendon Ruptures: A Meta-Analysis of Randomised Controlled Trials J Bone Joint Surg (Am) Boston: Vol … Rehabilitation Protocol: Achilles Tendon Rupture Repair Department of Orthopaedic Surgery Lahey Hospital & Medical Center, Burlington 781-744-8650 Lahey Outpatient Center, Lexington 781-372-7020 ... your physical therapy consult for 8 weeks after your surgery. • Patient must be willing to comply with the functional rehab protocol and strict guidelines. It is recommended that clinicians collaborate • Patient must be willing to comply with the functional rehab protocol and strict guidelines. Carefully monitor the tendon and incisions for mobility and signs of scar tissue formation. Acute Achilles tendon rupture a randomised controlled study comparing surgical and non-surgical treatment using validated outcome measures. Regular soft tissue treatments (i.e. ... 98: 24-32.Suchak AA, Spooner C, Reid DC, Jomha NM. A defect or gap in the Achilles tendon can usually be felt. Schilders E, Shilders E, Bismil Q, Metcalf R, Marynissen H. Clinical tip: Achilles tendon repair with accelerated rehabilitation program. Accelerated rehabilitation following Achilles tendon repair after acute rupture –Development of an evidence-based treatment protocol. Proprioceptive rehabilitation. Seated heel raises.
achilles tendon rupture accelerated rehab protocol