How to prevent lymph nodes from swelling after a mastectomy

How to prevent lymph nodes from swelling after a mastectomy

Recovery from a lumpectomy is usually fairly simple. To make sure it proceeds smoothly, you will typically need to closely adhere to your doctor’s instructions and get plenty of rest. You may also benefit from taking pain medication your doctor prescribes after a lumpectomy until the discomfort subsides. Additionally, you may do well to care for your incision per your doctor’s orders and avoid full showers or baths until after he removes your stitches.

One of the most important things to do after a lumpectomy is to follow your doctor’s orders. Your doctor will likely give you a list of things to avoid or to do after a lumpectomy as well as instructions for caring for the incision and the surrounding area. By following his instructions, you can avoid infection and undue pain, ensuring that you heal quickly and completely. If you have any questions about your recovery and what you should do to make it as smooth as possible, you can typically call your doctor’s office for assistance.

Since you may experience pain after a lumpectomy, once of the most important things you can do is make sure you have pain medication to keep you comfortable. Your doctor will likely administer such medication while you are in the treatment facility and may provide a prescription for your use at home. Even if you feel that you will not need it, it is usually best to have this prescription filled. This way, you have it on hand if you become uncomfortable.

You will likely need to rest after a lumpectomy; as with most types of surgery, it can prove tiring and emotionally draining. You can help yourself recover properly by resting when you are tired. This helps ensure that you can return to your normal activities and feel 100 percent sooner. In fact, if you make an effort to get plenty of rest, you may be able to return to many of your normal activities within just a few days of surgery.

Your doctor will typically provide instructions you will have to follow to properly care for the bandage over your incision, and you may also have a surgical drain in your underarm area or on your breast. Often, doctors remove these drains before the patient leaves the hospital, but some must remain until the follow-up appointment. If you have a drain, your doctor will explain how to empty it each day. You won’t usually have to do much to care for your stitches or staples, but your doctor will probably provide instructions for recognizing related problems or concerns. Additionally, he may recommend that you take sponge baths until your stitches are removed or they dissolve on their own.

Nicole’s thirst for knowledge inspired her to become a InfoBloom writer, and she focuses primarily on topics such as homeschooling, parenting, health, science, and business. When not writing or spending time with her four children, Nicole enjoys reading, camping, and going to the beach.

Nicole’s thirst for knowledge inspired her to become a InfoBloom writer, and she focuses primarily on topics such as homeschooling, parenting, health, science, and business. When not writing or spending time with her four children, Nicole enjoys reading, camping, and going to the beach.

This information describes how to prevent infection and reduce swelling in your hand and arm after your axillary lymph node dissection surgery. Following these guidelines may help prevent lymphedema.

About Your Lymphatic System

How to prevent lymph nodes from swelling after a mastectomy

Figure 1. Normal lymph drainage

Your lymphatic system has 2 jobs:

  • It helps fight infection.
  • It helps drain fluid from areas of your body.

Your lymphatic system is made up of lymph nodes, lymphatic vessels, and lymphatic fluid (see Figure 1).

  • Lymph nodes are small bean-shaped glands located along your lymphatic vessels. Your lymph nodes filter your lymphatic fluid, taking out bacteria, viruses, cancer cells, and other waste products.
  • Lymphatic vessels are tiny tubes, like your blood vessels, that carry fluid to and from your lymph nodes.
  • Lymphatic fluid is the clear fluid that travels through your lymphatic system. It carries cells that help fight infections and other diseases.

Axillary lymph nodes are a group of lymph nodes in your armpit (axilla) that drain the lymph fluid from your breast and arm. Everyone has a different number of axillary lymph nodes. An axillary lymph node dissection is a surgery to remove a group of axillary lymph nodes.

About Lymphedema

Sometimes, removing lymph nodes can make it hard for your lymphatic system to drain properly. If this happens, lymphatic fluid can build up in the area where the lymph nodes were removed. This extra fluid causes swelling called lymphedema.

Lymphedema can develop in the arm, hand, breast, or torso on your affected side (the side where your lymph nodes were removed).

Signs of lymphedema

Lymphedema can develop suddenly or gradually. It can happen months or years after your surgery.

Watch for these signs of lymphedema in your affected arm, hand, breast, and torso:

  • A feeling of heaviness, aching, or pain
  • A tight feeling in your skin
  • Less flexibility
  • Swelling
  • Skin changes, such as tightness or pitting (skin that stays indented after pressing on it)

If you have swelling, you may notice that:

  • The veins in your affected hand are less noticeable than on your other hand.
  • The rings on your affected finger(s) are tighter or don’t fit.
  • The shirt sleeve on your affected side feels tighter than usual.

If you have any signs of lymphedema or aren’t sure, contact your healthcare provider.

Lowering Your Risk of Developing Lymphedema

It’s important to prevent infection and swelling to lower your risk of developing lymphedema.

Preventing infection

You’re more likely to get lymphedema if you get an infection in your affected arm. This is because your body will make extra white blood cells and lymphatic fluid to fight the infection, and this extra fluid may not drain properly.

Follow these guidelines to lower your risk of getting an infection.

  • Be careful not to get sunburned. Use a sunblock with an SPF of at least 30. Reapply it often.
  • Use insect repellent to avoid stings and bug bites.
  • Use a lotion or cream daily to help protect the skin on your affected arm and hand.
  • Don’t cut your cuticles on your affected hand. Instead, push them back gently with a cuticle stick.
  • Wear protective gloves when doing yard work or gardening, washing dishes, or cleaning with harsh detergent or steel wool.
  • Wear a thimble when you’re sewing.
  • Be careful if you shave under your affected arm. Think about using an electric razor. If you get a cut while shaving, take care of it following the instructions below.

If you notice any signs of infection (such as redness, swelling, skin that’s warmer than usual, or tenderness), call your healthcare provider.

Caring for cuts and scratches

  1. Clean the area with soap and water.
  2. Apply antibiotic ointment, such as Bacitracin ® or Neosporin ® .
  3. Cover the area with a bandage, such as a Band-Aid ® .

Caring for burns

  1. Apply a cold pack to the area or run the area under cool tap water for about 10 minutes.
  2. Clean the area with soap and water.
  3. Cover the area with a bandage, such as a Band-Aid.
  4. Preventing swelling

Right after your surgery

Some mild swelling after surgery is normal. This swelling may last for up to 6 weeks. It’s often temporary and will gradually go away. You may also feel pain or other sensations such as twinges and tingling after your surgery. Follow these guidelines to help relieve the swelling after your surgery.

  • Do your exercises 5 times per day. If your healthcare provider told you to do them more or less often, follow their instructions.
  • Keep doing your exercises until you get back your normal range of shoulder and arm movement. This can take 4 to 6 weeks after surgery.
    • If you feel a stretch in your chest or under your arm, it may be helpful to keep doing the stretching exercises for even longer.
    • If you don’t get your normal range of motion back after 4 to 6 weeks, call your healthcare provider.

    Over the long term

    Doing the following things may help lower your risk of developing lymphedema.

    You might hear some people saying having lymph node dissection (lymphadenectomy) done is unnecessary; however, there is no other way to do a biopsy of the lymph node while in the body or performing the biopsy than returning them into the body.

    With the body having hundreds of lymph nodes throughout the body, filtering the lymph fluid, cancer cells can transfer to different node areas in the body. If tests show that cancer cells are evident, the doctor will recommend removing the lymph node to perform the biopsy to determine if the tests are correct.

    Removing the sentinel lymph nodes for biopsy can minimize how many of them will be removed. After removal, side effects may occur, but usually, your health care professional can manage them.

    Lymph Nodes Purpose

    Lymph nodes have an essential purpose in the health of the body, so removing them usually is a last resort, and the biopsy is only when necessary. The lymph nodes are part of the circulation system. They trap waste, cancer cells, and other debris in the system so they can be removed from the body. When overwhelmed with an infection, cancer, or other material, they will swell and become noticeable.

    There are three circulatory systems in the body. The first one is the lymphatic system (it can trap and filter larger waste particles than the venous system), which removes waste. The second one is the venous system with the responsibility to remove debris from tissues. The Third one is the arterial system, which circulates blood throughout the body. All three have vital roles to play in the works of the body.

    The Removal Process

    Lymph nodes are removed during a surgical procedure. The procedure is an outpatient surgery that will vary in length due to the number of lymph nodes being removed and their locations. If the sentinel lymph nodes are going to be removed, it will be after a dye test is done to identify which ones they are. Sometimes the biopsies will be done while the person is still in surgery so that additional surgery can be done at the same time if the lymph nodes have cancer cells. Some of the side effects of lymph node removal include pain, discomfort, and swelling. The side effects may subside, but the swelling can come and go depending on how the lymph circulates throughout the body.

    Staging The Cancer

    Lymph node removal is necessary to determine the cancer stage. If there is no lymph node involvement, it is easier to treat cancer. If there is lymph node involvement, then that means cancer has spread from the original tumor, and further testing will be needed. These are the stages of the disease:

    • Stage I – Carcinoma in situ (CIS), an early stage of cancer when the cells have not invaded surrounding tissue
    • Stage II and Stage III – localized disease, the tumor is in one area of the body with lymph node involvement
    • Stage IV – cancer has spread to other organs or throughout the body

    Different types of cancer have different criteria for the amount of lymph node involvement for it to be staged II or III.

    Conclusion

    Before having the lymph node removed and having lymphadenectomy performed, you may want to do research and get a second opinion. To minimize the number of lymph nodes that will need to be removed can be reduced by identifying the sentinel nodes and doing a biopsy on those.

    How to prevent lymph nodes from swelling after a mastectomy​Lymphedema is a common side effect among cancer survivors, but it can affect any patient whose treatment plan included lymph nodes being removed by surgery or lymph nodes being damaged by radiation treatment.

    Lymphedema is a swelling in the arms, legs, or other parts of the body caused by a build-up of extra lymphatic fluid. Lymphatic fluid cannot flow through the body normally if lymph nodes are removed or damaged. The swelling can be very painful, and it can cause skin and mobility problems. Lymphedema also puts patients at higher risk for infection in the affected areas.

    Talk to your healthcare team to find out if you are at risk for lymphedema. One of the best ways to manage lymphedema is to avoid things that may trigger it or make it worse. Prevention is key.

    If you are at risk for lymphedema, avoid the following:

    • If you had lymph nodes removed from under your arm, do not have your blood pressure taken from that arm.
    • Do not have blood drawn or receive shots or IVs in an area where lymph nodes have been removed.
    • Use SPF 30 or higher sunscreen to avoid sunburns.
    • Use insect repellent when outside to avoid bites that could lead to infection.
    • Avoid trauma or injury to the affected area.
    • Avoid heavy lifting with the affected arm.
    • No new tattoos in the affected area.
    • Do not wear tight clothing, bands, shoes, or jewelry on the affected area.
    • Wear a compression sleeve or stocking, if ordered by your doctor.
    • Compression sleeves for lymphedema need to fit correctly. An ill-fitting compression sleeve may make lymphedema worse.
    • Use unscented lotion daily to keep the skin moisturized.
    • Maintain a healthy body weight by eating a well-balanced diet.
    • Do light exercise or stretching.
    • Ask your healthcare team which exercises are right for you. Some exercises may make lymphedema worse.

    If you do experience the signs of lymphedema—swelling, pain, numbness, decreased mobility, or skin changes—tell your healthcare team right away. Your doctor may suggest that you see a physical therapist to help treat the lymphedema with massages, compression, and special exercises. To learn more about lymphedema visit My PearlPoint or the National Lymphedema Network.

    This article was co-authored by Marsha Durkin, RN. Marsha Durkin is a Registered Nurse and Laboratory Information Specialist for Mercy Hospital and Medical Center in Illinois. She received her Associates Degree in Nursing from Olney Central College in 1987.

    There are 9 references cited in this article, which can be found at the bottom of the page.

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    Your body has a number of lymph nodes, which act as filters for bad bacteria and viruses. If your lymph nodes are swollen, you can start to shrink them by treating any underlying injury, disorder or infection. Common sites for swollen lymph nodes are the neck, groin and underarms. If two or more areas are swollen, this usually indicates a generalized problem. To treat swollen lymph nodes you must treat the cause, if it is a bacterial infection, antibiotics will usually be prescribed, if the infection is viral, you can be prescribed drugs which manage your symptoms, but will have to wait for it to resolve on its own. If cancer is suspected, a biopsy will be taken for diagnosis and treatment. Talk with your doctor for advice. [1] X Trustworthy Source Mayo Clinic Educational website from one of the world’s leading hospitals Go to source

    How to prevent lymph nodes from swelling after a mastectomy

    As more people across the globe continue to receive the COVID-19 vaccine, we’ve learned quite a bit about the side effects that the vaccine can cause.

    Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

    But one side effect — swollen lymph nodes under your arms — has been getting more notice because it’s an overlapping symptom for other issues. It’s important to know what’s a side effect of the vaccine and what’s a sign of something that needs further attention.

    To better understand what’s causing this symptom and what you should know before getting your COVID-19 vaccine, we talked to diagnostic radiologist Laura Dean, MD.

    What are the COVID-19 vaccine side effects?

    The most common side effects of the COVID-19 vaccine include:

    • Fever.
    • Chills.
    • Muscle aches.
    • General fatigue.
    • Headaches.
    • Soreness at point of injection (also known as “COVID arm”).

    The side effects are typically mild, last between 24-48 hours and are most commonly felt after the second dose of the mRNA vaccines (Pfizer and Moderna) or the single Johnson & Johnson dose.

    Why does the COVID-19 vaccine cause lymph nodes to swell?

    Lymph nodes are part of the body’s immune system so, according to Dr. Dean, swollen lymph nodes are a potential side effect of any vaccine. “The whole point of the vaccine is to get your immune system to mount a response to whatever the vaccine agent is,” she says.

    But it seems that the COVID-19 vaccines can cause a more robust swelling in lymph nodes. And those swollen lymph nodes, like other side effects, vary from person to person. “We’re still learning about these vaccines and the side effects as more and more people receive them,” Dr. Dean says.

    The swollen lymph nodes generally appear a few days after someone receives the vaccine, on the same side of the body as they got the shot. “We’re still watching these examples, but right now we think that symptom subsides with a few days to a few weeks,” she adds.

    What do swollen lymph nodes usually mean?

    Swollen lymph nodes can sometimes be a symptom of cancer. But it’s important to remember that they can have a number of other causes. And while the COVID-19 vaccine appears to only cause swelling on one side, swelling in lymph nodes on both sides of the body is also not necessarily a sign of cancer.

    “You see general lymph node enlargement — under the arms, in the chest or groin — with something like lymphoma,” says Dr. Dean. “But there are other reasons you’d see that, too, which are far less serious than cancer.”

    • A cold or a case of the flu.
    • Sinus infection. . .

    There are additional conditions, too, that Dr. Dean says healthcare providers may look into. “We address the issue by taking a very detailed patient history and looking for other conditions that may cause the swelling like rheumatoid arthritis, lupus or autoimmune diseases.”

    And, yes, this includes swelling on just one side. “We don’t want to miss something because a lymph node on just one side is swollen,” she adds. “But we’ve also added questions about recent COVID-19 vaccines to our screening questions to make sure we’re getting a full view of what might be affecting the patient.”

    Still, if you’re concerned by the appearance of swollen lymph nodes within a day or two after receiving your COVID-19 vaccine, it’s worth contacting your healthcare provider. With their knowledge of your medical history, they have the necessary context to make a full evaluation.

    Swollen lymph nodes as a sign of breast cancer

    It’s the location of the lymph nodes involved with this particular side effect that’s causing concern. Many times (but not always) the location of a person’s lymph node swelling corresponds to the site of infection. For many breast cancer patients, that includes the lymph nodes in the armpits.

    “If breast cancer moves outside of the breasts, it tends to go to those patterns of the lymph fluid inside the breast tissue,” Dr. Dean explains. “It’s a very integrated system, so it’s one of the areas we closely scrutinize.”

    Because early detection is so key to treating breast cancer, it’s understandable that this overlapping symptom is causing a little bit of confusion and even alarm in many patients.

    Does this affect my preventive care plan?

    The most important thing, Dr. Dean says, is that patients maintain their preventive care plan for breast cancer, especially mammogram screenings.

    The Society of Breast Imaging recommends scheduling your mammogram either before your first dose of the COVID-19 vaccine or about four to six weeks following your second dose, if possible. If that’s not possible, though, it’s important to keep both your scheduled screening and your vaccine appointment.

    “We’ll work with you to explain what’s going on, what we see and what might be a side effect,” Dr. Dean adds. “And if there’s potential overlap, you can schedule a short-term follow-up screening for a few weeks later just to be safe.”

    The bottom line: get vaccinated

    Again, Dr. Dean stresses that there’s no reason to be alarmed about getting swollen lymph nodes from the COVID-19 vaccine. “This type of reactive change that we’re seeing with the COVID-19 vaccine is exactly what we should see,” she says. “It’s your body mounting the immune response as it’s supposed.

    While those enlarged lymph nodes may be worrisome, she adds that healthcare providers are aware and monitoring them in patients. “We’re keeping an eye on this side effect and when it comes to your mammogram screening, we’re ready to explore any abnormalities in that context.”

    Finally, she reiterates how important it is to maintain your preventative care appointments despite these side effects. “It’s extremely important COVID-19 vaccinations continue. And it’s also important to know that we’ll never turn any patient away from a mammogram screening for getting their vaccination. We’re armed with as much information as possible and we’ll work with every patient to make sure they get the care they need.”

    When you have swollen lymph nodes, your first thought shouldn’t be, “I have cancer.” They’re much more likely to be caused by infections or a disease that affects your immune system, and they will often clear up as your body heals.

    But sometimes, cancer cells will travel through your bloodstream and end up in your lymph nodes, or even start there.

    Your doctor can help you figure out what’s causing the changes in your body.

    Why Lymph Nodes Swell

    There are more than 600 small, kidney bean-shaped lymph nodes in clusters throughout your body — under your neck, in your armpits and groin, and in the middle of your chest and belly. These store immune cells and act as filters to remove germs, dead and damaged cells, and other waste from your body.

    Swollen lymph nodes are a sign that they’re working hard. More immune cells may be going there, and more waste could be building up. Swelling usually signals an infection of some kind, but it could also be from a condition like rheumatoid arthritis or lupus, or rarely, cancer.

    Often, swollen lymph nodes will be close to where the problem is. When you have strep throat, lymph nodes in your neck may swell. Women who have breast cancer may get swollen lymph nodes in their armpit.

    When several areas of lymph nodes are swollen, that suggests the problem is throughout your body. It could be something like chickenpox, HIV, or a cancer such as leukemia or lymphoma.

    When to See a Doctor

    You’ll often have a good idea why a lymph node is swollen — you’ve got a cold, your tooth is infected, or you have a cut that isn’t healing well. If you can’t come up with an explanation, it may be time to get checked out.

    Lymph nodes that are around 1/2 inch or bigger aren’t normal. They shouldn’t feel hard or rubbery, and you should be able to move them. The skin over them should not be red, irritated, or warm. And the swelling should go away within a couple of weeks. You should see your doctor if your lymph nodes appear abnormal.”

    Other symptoms are also a reason to make an appointment:

      or swallowing that doesn’t break without trying to

    Getting a Diagnosis

    Your doctor will probably try to rule out reasons other than cancer first. They’ll do a physical exam and ask about things that have happened, like if you’ve:

    • Been scratched by a cat
    • Been bitten by a tick
    • Eaten undercooked meat
    • Had risky sex or injected street drugs
    • Traveled to certain places or areas

    They’ll want to know what medications you’re taking and other symptoms you have.

    Swollen nodes that are close to your collarbone or the lower part of your neck when you’re over 40 are more likely to be cancer. On the right side, related to the lungs and esophagus; on the left, organs in your belly. Swollen lymph nodes in your armpit when you don’t have a rash or sores on your arm can also be suspect.

    If your doctor thinks your swollen lymph nodes could be cancer, tests and imaging can confirm the diagnosis or point to something else. Based on where the cancer might be, you could get a chest X-ray, an ultrasound, a CT scan, or an MRI. A scan called FDG-PET, which stands for fluorodeoxyglucose with positron emission tomography, can help find lymphoma and other cancers. And you’ll probably get a biopsy. They’ll take either a sample of cells from a node, typically using a needle, or remove a whole node. The sample gets sent to a lab so a specialist can check it with a microscope for cancer.

    Otherwise, you’ll usually start with a complete blood count (CBC) to get a picture of your general health as well as more detailed information about your white blood cells, which fight infection. Depending on your other symptoms and your history, your doctor may want additional blood tests or x-rays, too.

    If these tests don’t show another cause and the swollen nodes don’t go away in 3-4 weeks, your doctor will probably do a biopsy. Since the swelling will often go away or another cause will be found while you’re waiting to do a biopsy, the delay prevents people from getting procedures they don’t need. And even if it is cancer, you should still be able to treat it effectively.

    When you have swollen lymph nodes throughout your body, your doctor will ask for a CBC, a chest X-ray, and an HIV test. If these are normal, you might get other tests, perhaps for tuberculosis or syphilis, an antinuclear antibody test (which checks your immune system), or a heterophile test (for the Epstein-Barr virus). The next step is a biopsy of the most abnormal node.

    What Does Cancer in a Lymph Node Mean?

    Cancer in your lymph nodes may point to lymphoma or another blood cancer, or may be a cancer that has spread from another site.

    Based on the source of the cancer cells and how far away that is from the swollen nodes, your doctor will recommend a treatment plan. It could include surgery, radiation, or chemotherapy, or a combination of treatments.

    Sources

    Insight, Dana-Farber Cancer Institute: “If My Lymph Nodes Are Swollen, Do I Have Cancer?”

    How to prevent lymph nodes from swelling after a mastectomy

    Lymphedema in breast cancer survivors occurs due to blockage of the lymph carrying vessels after cancer therapy such as lymph node removal surgery and radiotherapy as a side effect of these treatments.

    Breast cancer survivors may have a higher risk of abnormal lymph node swelling (lymphedema) in the arm, armpit, hand, breast, or torso throughout their life because there is no definite period after cancer treatment when the risk no longer exists. Around 40% of women treated for breast cancer face a lifetime risk of lymphedema after cancer treatment.

    Usually, lymphedema develops within two to three years of your breast surgery. However, it may still occur years after you finish all treatment (during the months or even years after the ending of treatment). If it occurs right after your breast surgery, it may usually only last for a short period and then go away.

    It is one of the causes of daily stress and psychosocial issues in breast cancer survivors because there is no such cure for this condition. Many times, they will be unaware of this condition.

    What does breast cancer mean?

    Breast cancer means a disease in which the cells of your breast abnormally grow out of control. It commonly occurs in women than in men.

    There are different types of breast cancer depending on the type of cells that turned cancerous (grow wildly). It may begin in different parts of your breast. However, mostly, it begins in the ducts or lobules (glands that produce milk) of your breast. Further, it may spread outside your breast through the blood vessels and lymph vessels (carries the waste products and toxins). When these breast cancer cells spread to other parts of your body, it is called metastasis.

    According to the Centre of Disease Control and Prevention, women aged 50 years or more are most likely to suffer from breast cancer. However, around 11% of all new breast cancer cases in the United States were of women aged younger than 45 years.

    What does lymphedema mean?

    Lymph nodes are small structures that filter out harmful substances such as toxins from our body. Clear lymph fluid in the lymph nodes also contains white blood cells that fight against the infection.

    Blockage into these lymph carrying vessels may cause the accumulation of lymph, which may result in swelling of the lymph nodes called as lymphedema (particularly in your arm/armpit or leg/groin area). Causes of blockage may be an infection, scar tissue formation, a blood clot in a vein, radiation, or other cancer treatments.

    Your risk of lymphedema is high if you have

    • Excessive weight.
    • Infections. .
    • Certain lymphatic diseases.
    • Removal of subsequent lymph nodes.

    How to prevent lymph nodes from swelling after a mastectomy

    SLIDESHOW

    How can you reduce the risk of lymphedema after breast cancer treatment?

    If you have undergone breast cancer treatment, your doctor/oncologist/oncosurgeon may inform you about optimal self-care measures to reduce your risk of lymphedema that include

    • Optimal healthy weight control by
      • Healthy lifestyle practices such as a healthy diet.
      • Exercises.
      • Long-term physical therapy to drain the fluid from your arm or leg.
      • Wearing gloves while working in the garden, house, or fields.
      • Avoiding using scissors for nail cutting.
      • Using an electric razor to shave underarms.
      • Taking care while playing with pets.
      • Using insect repellents or mosquito nets to prevent insect bites.

      These optimal self-care methods allow lymph drainage and reduce further inflammation and infection of the lymphatic system and repeated cellulitis. Practicing these self-care methods may reduce your financial burden due to repeated sufferings and its effect on daily quality of life including work-absenteeism and unemployment.