May 27, 2022

Beating Lymphedema with Lymphatic Massage Expert Christine Galione, MSPT, CLT

Beating Lymphedema with Lymphatic Massage Expert Christine Galione, MSPT, CLT

When and if lymph nodes have to be removed in the course of breast cancer treatment, lymphedema is a persistent aftereffect that must be treated and cared for following surgery, sometimes for many years. Special guest and lymphedema specialist Christine Galione, MSPT, CLT is a physical therapist and expert lymphatic massage practitioner at Scripps Memorial La Jolla who has been helping breast cancer patients with lymphedema therapy since 2004.

When and if lymph nodes have to be removed in the course of breast cancer treatment, lymphedema is a persistent aftereffect that must be treated and cared for following surgery, sometimes for many years.

Special guest and lymphedema specialist Christine Galione, MSPT, CLT is a physical therapist and expert lymphatic massage practitioner at Scripps Memorial La Jolla who has been helping breast cancer patients with lymphedema therapy since 2004.

Christine helps us understand what the lymph system does, how it functions, and the issues that can arise after removing them, including:

  • What cording is and how they treat it
  • When to wear (and not wear) compression sleeves
  • How to get back to regular exercise and weight lifting
  • Helpful tips for with air travel
  • Tips for ensuring your lymphatic massage is covered by insurance

Although it can be very scary for some people, Christine assures us that lymphedema is treatable, and the sooner you can get to therapy the better.


See the illustration of the lymph system mentioned by Christine in this episode

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About Breast Cancer Stories

Breast Cancer Stories follows Kristen Vengler, a 56 year old single empty nester in San Diego, from her diagnosis of hormone positive breast cancer through chemotherapy, mastectomy & breast reconstruction, radiation, and whatever happens after that.

In 2020, Kristen moved from Austin to San Diego to be near family and start her life over after a life-shattering workplace trauma. A few months later she had that terrifying moment in the shower we all hope we never have.

From her breast cancer diagnosis, through chemotherapy, breast reconstruction, and radiation, we experience each new milestone as it happens. This podcast is about what happens when you have breast cancer, told in real time.

Host and Executive Producer: Eva Sheie
Co-Host: Kristen Vengler
Editor and Audio Engineer: Daniel Croeser
Theme Music: Them Highs and Lows, Bird of Figment
Production Assistant: Mary Ellen Clarkson
Cover Art Designer: Shawn Hiatt

Breast Cancer Stories is a production of The Axis.


Special Guest: Christine Galione.


Eva Sheie (00:05): This is a story about what happens when you have breast cancer, told in real time.

Kristen Vengler (00:13): Hey Christine, it's good to have you here.

Christine Galione (00:16): Thank you for having me.

Kristen Vengler (00:17): Absolutely. It's so fun to see you without your mask, because I have only seen you with your mask until the other day. You have such a beautiful smile.

Christine Galione (00:26): Thank you.

Kristen Vengler (00:26): Can you tell us a little bit about yourself?

Christine Galione (00:29): Sure. My name is Christine Galione and I am a physical therapist. I work at Scripps Memorial La Jolla. And as of tomorrow, I will have been there for 20 years.

Kristen Vengler (00:41): What?

Christine Galione (00:41): Yes, I started when I was two. But I've been doing lymphedema therapy since 2004. I started in the hospital setting and then after about a year, transitioned to the outpatient department and have been there ever since.

Kristen Vengler (01:00): That's awesome. So she's down in the basement of Scripps Memorial Hospital.

Eva Sheie (01:04): So you don't have windows in your room, Christine?

Christine Galione (01:07): Nope.

Eva Sheie (01:08): And you've been in that room for how long?

Christine Galione (01:10): 18 and half years.

Eva Sheie (01:12): Oh my gosh. So before we go too far, the reason we're here with you today, and thank you for being here, is that a while back when we learned that Kristen had a dozen lymph nodes removed in surgery-

Kristen Vengler (01:27): Close. Yeah, 11.

Eva Sheie (01:28): 11. We very quickly figured out that we didn't really know anything about lymph nodes. So give us the basics. What are they, what do they do, and how many do we have?

Christine Galione (01:40): Okay. So your lymphatic system is essentially your body's waste removal system. So your lymph system basically picks up the normal materials that your cells don't need. So every day, our arteries are bringing healthy blood flow to our muscles and all of the structures in our body. And so our body's using the protein, the water, the potassium, calcium, sodium, all the normal vitamins and minerals that we need. But we're not 100%efficient. So the stuff that we don't need gets kind of discarded into the space right underneath our skin. And so the small molecules, like water, potassium, calcium and sodium will actually soak back through our veins and exit through our venous system. And things like protein, which is very long chains of molecules, they're too big to soak back through the veins. So they need to go through a system that has a physical opening, which would be our lymphatic system.

Christine Galione (02:37): So our lymphatic system is a series of vessels and nodes, and the vessels actually open. And when they open, it allows larger molecules, like a protein, to enter into the system. The other thing that it allows into the system, let's say you get a cut or a scrape and you get a foreign body in there, maybe a virus or a bacteria, the white blood cells will collect those and bring them into the lymph system. Then once the fluid's in the valves, it travels just like a car would travel down the freeway, and it stops at the checkpoint, which is your lymph node. And that's actually your filtration system. So it is responsible for determining is this fluid just normal fluid. And if it is, it just moves it along. If there's a virus, a bacteria, or foreign body, it's going to attack it. So that's kind of the function of the lymph system. It's like our body's waste removal system.

Kristen Vengler (03:28): So can I ask a real quick question? When you said virus, I know that I had a flu shot shortly before having a mammogram, and one of my lymph nodes was enlarged.

Christine Galione (03:38): Yeah. And think of when you have a head cold and you kind of touch the inside of your neck and you're like, "Ooh, that's tender." The bump or the tenderness you're feeling, those are your lymph nodes. And they're enlarged because they're trying to neutralize and attack whatever head cold or virus or bacteria is in there.

Kristen Vengler (03:54): Great.

Eva Sheie (03:56): So in Kristen's case, she had cancer in her lymph nodes and that was why they removed them. But why did they only take 11 of them?

Kristen Vengler (04:05): So Dr. Rivera did something called a sentinel node mapping and biopsy. And so what he did is he injected some radioactive material into the tumor and then he looked to see where that liquid was going in the lymph system. And so then he took the lymph node closest to that and did a biopsy right there in the OR, and found that there was cancer in that lymph node. So he took 11 total to be sure, to try to get all the cancer that may be in the lymph nodes.

Eva Sheie (04:38): So was it like, and I don't know which one of you can answer this, but was it like a radius around the one that he biopsied? He took one and then the 10 more that were closest to it?

Christine Galione (04:49): Typically, when they do a sentinel node biopsy, they inject the dye and they wait for the lymph nodes to pick up the fluid. And so when they do the scan, the lymph node or nodes that are the brightest are the lymph nodes that were the most active and picked up the most fluid. And so those are going to be your most active nodes. So they're the ones that are most likely to pick up a cancer cell if it has left the tumor. And so that's why they do the sentinel node biopsy and take out the brightest lymph nodes.

Christine Galione (05:19): Lymph nodes are kind of, if you think of like a cluster of grapes and then you take those grapes and you plant them into a vat of Crisco, most lymph nodes are within a fat pad. So it's a strange visual, I know, but that's what it is. And so they take out the nodes that are kind of burning the brightest, but there are usually other nodes there that may or may not have picked up the fluid. So when they get your count of 11, many times, it's the pathologist under a microscope that identifies that there were other lymph nodes there that maybe didn't pick up the fluid because at the moment they weren't active.

Kristen Vengler (05:52): Right. So Dr. Rivera had no idea he was taking out 11. He was taking out what was close and what lit up, and then those in the fat pad, in the Crisco, right? Basically, to get all those.

Christine Galione (06:06): Mm-hmm (affirmative).

Kristen Vengler (06:07): Yeah. Okay.

Christine Galione (06:08): So the good news is the average person has between 35 and 45 lymph nodes and [inaudible 00:06:15], and between six and 700 lymph nodes throughout the entire body. So we have many, many lymph nodes. So the one thing to know about lymph nodes is it's not like fingers and toes, where it's pretty predictable how many people are going to have. There is a great variability and they aren't detectable with the naked eye. We've had patients come in and say, "Well, my doctor took out 11 lymph nodes, but my friend's doctor took out two and her friend's doctor took out 27. Why?" And the truth is, those were the lymph nodes that were in the fat pad, those were the lymph nodes that were attached to the sentinel node or maybe you had a couple sentinel nodes that they removed.

Christine Galione (06:53): They don't know the exact number until they get it under the microscope because the lymph nodes that don't pick up fluid aren't going to light up until you get them under the microscope. So that's why the numbers vary. It's not that, oh, one surgeon was better because they only got two, it's just your body's makeup.

Kristen Vengler (07:11): Is it kind of like the grape cluster? So he basically was trying to get that cluster out.

Christine Galione (07:16): Yes.

Kristen Vengler (07:16): Right. And so my cluster could have 10, it could have 12, it could have 25, it could have 35, just depending on me, my body, my makeup and where it is in the body. Is that right?

Christine Galione (07:27): Exactly. And in the armpit, there are essentially four layers of lymph nodes. So back in the '60s, '70s and early '80s, when they were doing the radical mastectomies, they took out all four layers of lymph nodes. Well, layers three and four are actually deep to our muscles. So back in the day, they took out the pec muscle. They took everything down to the rib cage. Now, when they're doing the sentinel node biopsy, they're working most likely on the level one lymph nodes, possibly level two. So all of those other lymph nodes are left intact. So I think that's important for people to know, is that just because some have been removed, there are still others there.

Kristen Vengler (08:06): Sure. So can you talk a little bit about where the lymph nodes are? I know they're all over your body because you hear so much about, "Oh, it's in the lymph node," and you get that look like. And it's scary because I remember when I woke up, Dr. Rivera said, "If we took lymph nodes out, they'll be another drain. You'll have three drains instead of two." And I was crestfallen that I'd had three and I saw that as a death sentence because I thought, "Oh wow. The cancer got into my lymph system, which means it can go all over my body." And then we can talk about actually what lymphedema is. But I just wanted for people to understand where are the lymph nodes, and why is it important to get the cancer from the lymph nodes?

Christine Galione (08:50): The taking of the lymph nodes is really for staging purposes. So it's going to usually determine what the adjunctive therapies are after. So if there is cancer in the lymph nodes, then it's going to determine what either chemo or radiation or combo thereof is probably going to be needed. So it's kind of a way to help the doctors pick what therapies are coming next to give the best long term success and kind of minimize the risk of recurrence. So it's really a diagnostic tool for them to go, "Okay. Yes, we do have cancer in the lymph nodes. We're going to need to look at chemo and radiation," or "No, we don't." Essentially, it's helping with a cost benefit analysis of how much is it going to reduce your risk of recurrence by going through these different therapies? So that's why they take the lymph nodes, because it just helps them get a clearer picture.

Kristen Vengler (09:48): Sure. In my case, I had chemo beforehand. And so I'm sure that my lymph nodes were going crazy with the chemo and had I not had lymph node involvement, they would've probably just recommended radiating the chest wall. But instead, I had a 45 minute situation where there were probably 10 to 12 different areas that they were radiating. And so I didn't really understand why they're radiating so many smaller areas until now I'm understanding these little clusters of grapes, lymph nodes, are in my neck, they're in my collar bone, they're in my sternum. And so along with the anatomy of the breast lymph nodes, where else do they go?

Christine Galione (10:28): So you have a large group of lymph nodes right behind your ears. They are along the breast bone, down the spine, inside the elbow, behind the knee, the groin, and a lot deep in the gut. So 90% of our lymph system is superficial. So it's kind of right underneath the base of the skin and it runs along with those superficial veins and arteries that we can see when we look down in our hands and our wrists. The other 10% is more deep in our gut. And so those also deal with digestion as well, but 90% of the system is literally right under the base of our skin.

Eva Sheie (11:05): When you see people who've had lymph nodes removed, like Kristen, what kind of issues are they having because those nodes are no longer there? What kind of problems does it cause when they're not there anymore?

Christine Galione (11:20): So if you think of your lymph nodes like the waste removal freeway, if you will, when you have lymph nodes removed, it's potentially like closing down some lanes of a freeway or maybe even putting potholes on the road. And so when you have lanes closed or you have potholes, traffic has to slow down to go around it. And so if you think of the fluid in our body, like the traffic and there's a traffic backup, essentially what you're going to get is swelling. So for a lot of people, the first signs that maybe their system isn't being as efficient as it needs to be is they'll start to feel some heaviness or achiness in the arm, like there's fluid being left behind and the arm's getting a little heavier, but doesn't look any different. And then from there, if it's not treated at that point, then they may start to down the line, notice that maybe their watch is a little bit tight or some jewelry, whether it's a bracelet or rings or clothing, feels a little tighter on one arm. And then they'll start to see some actual swelling.

Christine Galione (12:21): Just for people who maybe are immediately post-surgery, listening to this and are like, "Oh my gosh, I have swelling," not all swelling is lymphedema. So I do want to let people know that if you are experiencing swelling after surgery, that is a completely normal thing. What we want to make sure is that people don't stay swollen. And so I keep referencing the arm. I do want to clarify that you can get swelling in the breast, the trunk and the arm. It's not just the arm. And so a lot of times, we'll have patients say, "Gosh, my arm feels fine, but I'm starting to notice some heaviness," whether it's in the breast or the trunk, the side of the body, we want to keep that fluid moving so that there doesn't get to be a backup so that there isn't lymphedema down the line.

Christine Galione (13:08): So your lymphatic system relies on your body's natural movements and rhythms to function. The system is anchored into the base of your skin. So every time your skin stretches as you're moving or as your muscles contract and form a muscle pump, it is stimulating the lymph system to move. Now, for someone who has swelling, the lymph system can't necessarily open and close as naturally as it would like because of that extra congestion, and that extra congestion can just be normal, post-operative swelling. But what we like to do is keep that fluid moving and help move it out faster so that it doesn't start to clog the system and then make it more difficult to function.

Eva Sheie (13:51): So in a lymphatic massage, like what you do, Where does the fluid actually go then?

Christine Galione (13:59): So when you stretch the skin, you actually pull on the initial part of the lymphatic system and the valves open. And so I kind of think of that like the green lights, and I don't know if every state has the green merge lights like California does. So I apologize for anyone who's not in California, that this reference doesn't make sense for. But in California, when you need to get on the freeway, there is a stop light and it will turn green and two cars can get on and then it turns red. And then a couple seconds later, it turns green again, and two more cars can get on. And so that changing from the red to the green is like the massage stroke. And so when you massage and you stretch the skin, that's like turning on the green light and allowing the fluid to merge onto the freeway.

Christine Galione (14:41): So the massage stroke is how we open up the system and allow the fluid that's trapped underneath the base of the skin to get onto the freeway. Once it's on the freeway, your lymphatic system moves throughout your body, much like your food moves through your digestive tract. It's a wave like propulsion. And so let's take the example of the arm. So if I'm massaging someone's arm and the fluid gets into the lymph vessel, it's going to go to the lymph node, possibly in the elbow or in the armpit and the lymph node's going to check. And if it's just our normal body waste, it's going to ship it on. The lymph system travels through your body and it joins up with your lymphatic system right before the venous system empties into the heart. From there, your heart's going to move it to your kidneys and you're going to pee it out.

Speaker 1 (15:26): So what would happen if you did not massage it out? What kind of trouble would you get in, if you didn't actually maintain or manage any kind of fluid buildup?

Christine Galione (15:37): Potentially, it could get worse because when you leave some fluid behind, it's going to make it harder for the system to open. When it's harder for the system to open, more fluid gets left behind. And so it becomes this vicious cycle and fluid has to go somewhere, and fluid always is going to find the path of least resistance. And for us, our bodies are elastic, our skin stretches. And so path of least resistance, a lot of times, is just to make this skin stretch and swell. And the truth is that doesn't happen very often, because most people come in and get help much quicker than that. But if you really truly just said, "I'm going to do nothing," it will progress. And at some point, if the skin gets so taught and so stretched that it can't stretch anymore, the fluid still needs to find a way out. So it could create an opening in the skin or a wound and it would start to flow out that way. We typically do not see that with our arm patients, we will more see that with our lymphedema leg patients.

Kristen Vengler (16:36): You have explained that so well and so clearly. When I first saw you, we worked a lot on the cording. And so can you talk about that, now that we understand the lymph highway, what is cording and how does that work?

Christine Galione (16:51): So cording is essentially a calcification of what we believe to be the superficial lymph vessels. And the reason I say believe to be is because we have never gone in and dissected someone to go, yes, that's your lymph vessels. And with our superficial lymph vessels, they run so intertwined with our superficial veins and arteries that based on the pathway, it would be impossible to determine which ones they are.

Christine Galione (17:21): But the few things that we know that lead us to think this is probably the lymph vessels versus a vein or an artery is for starters, cording seems to typically happen after a lymph node dissection in the axilla. There are these kind of unusual cases of it happening in the legs, but the vast majority happens in the arm and after lymph node dissection. We aren't seeing orthopedic shoulder patients coming in with cording. We're seeing breast cancer patients who have had a lymph node dissection coming in with cording. And so our best scientific educated explanation of what cording is at this time is that there is a phenomenon that happens where calcium wants to bind to the lymph vessels and it basically creates a cord or a guitar string in the arm. So you go to move your arm and all of a sudden it is stuck and it can be painful. And sometimes, you can look down and see an actual cord and it's limiting your motion because calcium is not flexible.

Kristen Vengler (18:26): So when Christine would work on the cord, she would massage the cord. And there were several times where it was like this warmth when it released. And so can you explain a little bit about that? I know what it felt like to me. It felt like a relief

Christine Galione (18:42): When the cording releases, very often there'll be like a little audible ping or almost sounding like a knuckle crack or popping a bubble wrap and almost feels like a little bit of a recoil, almost like an elastic snapping. And so as the therapist, I can usually feel the recoil. I've had many patients tell me that they feel this warm sensation. And the best guess of what we have that is that there was either fluid in that vessel when it calcified, and now it's just releasing to be absorbed to the body. Or sometimes we'll have patients that get like a teeny little bruise and it usually looks like an old bruise, that's kind of that yellowy pale purple or blue. So it doesn't look like a real fresh bruise. And so what we're also thinking is when that cord releases, because it runs so intertwined with the veins and arteries, that maybe a vein was disrupted during that release process and that's where the bruising and the warm feeling comes from.

Christine Galione (19:39): And so with cording, because we believe it is a lymph vessel, basically what we're doing is the manual lymphatic drainage along the line of the cord. And so really, the massage is just meant to be a stretching of the skin because our lymph vessels are anchored to the skin. So if we anchor the skin on one side and stretch it, we're going to constantly be providing a little pull on that cord in the stretch. And for anyone out there right now who has cording, it is important to know cording will resolve. It can potentially resolve on its own if you do nothing. But if you do the manual lymphatic drainage and the gentle stretching, it will likely resolve faster. We do not want people forcing their cords to break. And the reason for that is when cording is ready to release, it will release. It doesn't need to be forced.

Christine Galione (20:29): And if you force it and we've had stories where, whether it's a family member, the patient themselves, a medical professional, they're like, "Oh yeah, we can take care of that." And they just did a "swish" and stretched the cord in both directions. And yes, it released. It was very painful for the person. What happened is the body perceived that as traumatic and it swelled in response. And so that person ended up with more swelling and just had to do more to get their lymphedema under control. So they didn't have lymphedema going in, but that trauma and that increase of fluid ended up starting that process.

Christine Galione (21:05): So we want people to be very careful with how they're doing their stretch. So we always say the treatment should feel kind of strainful, like we're working on it, but not painful. And to the point of people doing absolutely nothing, which that is an option. What we do get concerned with is if people don't do anything and don't put any stretch on it are the other structures in the shoulder going to tighten up. And so when the cording does release, they still won't have their full range of motion because of now orthopedic issues. So there's got to be a happy medium in the treatment.

Kristen Vengler (21:36): And how common is cording?

Christine Galione (21:38): It's hard to put an exact number on it. What they can say is it typically affects younger, healthier fitter women. Not as much as our older population.

Kristen Vengler (21:49): I love that you just said that because I feel not young and not fit and we had a lot of work to do. So thank you so much for saying that. What I have come across in talking to the women who are just getting breast cancer diagnoses and they found out that they have cancer in the lymph node, or lymph node dissection, just a biopsy had proved there was cancer there, the fear around lymphedema is so huge. And so can you say anything to help quell those fears a little bit?

Christine Galione (22:27): Yes. That's been huge actually through my whole career, is sometimes we're getting patients who are explaining to them what the lymph system is or what lymph node dissection does. And they're like, "Why didn't my doctor ever tell me this? I wanted to know." And my answer sometimes is some of the doctors are afraid to tell patients about the lymph node dissection part because there have been patients who have chosen not to do it because they're more afraid of the lymphedema than the cancer. As a lymphedema therapist, lymphedema is very treatable. There's so much we can do for it. So I would hope no one would ever not get the full information about their cancer on the fear of lymphedema. I think, for some people, it's because seeing the lymphedema and the swelling is a daily reminder that you had cancer. So you could be cancer free, but there's always that reminder. And for some people, that is so powerful and so traumatic that actually lymphedema is worse for them. But I do want to assure people, lymphedema is very treatable and the sooner you can get to therapy, the better.

Christine Galione (23:37): And so to talk a little bit about the different stages of lymphedema. So the first stage is the subclinical phase, which means the fluid is starting to accumulate. But if you just looked, you wouldn't see a difference. But at that phase, people are starting to say, "Gosh, my arm feels heavier. My breast just feels heavier."

Christine Galione (23:58): And so what is happening at that point is the fluid is starting to fill in the space. And it's almost like if you have a kitchen sponge and you take that rectangular kitchen sponge out of the packaging and it's nice and light, and then you submerge it in water and you pick it back up. Now it's a lot heavier because that fluid has filled in the space. That is subclinical lymphedema. If we can get patients in that phase, that is where we have the chance to possibly reverse the process. So whenever I do community talks or presurgical talks, I always tell people come in when you just think you have that ache or the heaviness and you don't see swelling because swelling's actually one of the later signs of lymphedema, not one of the earlier signs.

Kristen Vengler (24:46): Once you're maintaining or trying to prevent it, like Kristen is, is this something you have to do forever?

Christine Galione (24:54): It's something you always need to be mindful of because with the lymph system, is it doesn't regenerate as well as the veins or the arteries. So a lot of times, once the system has been removed, there may be a little bit of regrowth, but it's not significant. We have to remember, this is a system that relies on our body's natural movements and rhythms to function. So if someone's so fearful of doing anything that they don't move, then they're actually going to increase their risk. So we want people to exercise and to go out and do activities. We just want them to be smart about how they do it.

Kristen Vengler (25:29): We talked about when I was flying, putting on a compression sleeve. Is that something that if I'm... I want to go back and do Pilates, and I've just been really, really hesitant about it because I don't want to overdo that arm and don't want to stretch so much. And so is that, would I wear my compression sleeve to Pilates or to exercise, is that going to help me?

Christine Galione (25:47): You could absolutely wear your sleeve, it will be another support for your skin. And also, just when you go back, if you're going back with a Pilates instructor, just let them know, "Hey, there are certain things I need to reintroduce movement to my arm, just in a little bit slower mechanism." And so it's all about listening to your body. Because everyone's going to be a little bit different. So when you're working out, it's all about the quality of the movement you're doing, not the quantity. I start all of my patients with one pound, cause I want to reintroduce movement to their muscles in a way that's not traumatic. And I say, we do it until it feels easy. And then we do it for one more week. And then we change one thing, whether it's the amount of reps or the weight or the frequency, we change one thing. So we get people back to their regular activities. It's just a slower, longer process than if they just had a traditional orthopedic surgery or injury.

Kristen Vengler (26:41): Right. And so what you're saying is basically I shouldn't just go to the gym and start with 10 pound weights on each side and do 12 reps until I'm completely fatigued, right? Three times.

Christine Galione (26:50): Please don't. Yes. Think of the trauma your upper body has been through, even if you had no side effects and everything went according to plan, it's still surgery, it's still traumatic. And so just learning how your body reacts is important. And so just start slow and progress slow because if you don't, we can't reverse that. I think people would be happier saying, "Oh, well it took me six months to get back to my routine. And man, I probably could have been back at four." They're not going to regret that. But they're like, "Man, I should have waited six month, and I tried to get back at four days and now I'm swollen." They're going to second guess that.

Kristen Vengler (27:36): Yeah, yeah. Absolutely.

Christine Galione (27:39): So I wanted to talk about the risk of lymphedema and air travel. What they have found is if you have had symptoms of lymphedema, symptoms of swelling, you should wear a proper fitting sleeve for travel. What was happening is people were maybe getting their sleeves right after their surgery. Didn't really need them except for travel. So they put them in a drawer and let's say five years later, they went on a trip and said, "Oh, I should get my sleeve out." Well life happened and they gained 10 to 15 pounds in that time. Now their sleeve was too small, but they wore it on the plane anyway and it created a tourniquet and it actually impeded the lymph flow. The key is wearing a properly fitted sleeve. So if you have not traveled recently and your sleeve is old and you think you may have gained or lost weight and you want the sleeve, I highly recommend going to a vendor for a refit and make sure that either your sleeve is the proper size or that you get a new, proper one.

Christine Galione (28:37): So if we think about the process of traveling, for most of us, it can be a stressful, "Are we going to get to the airport on time? Is there going to be a long line? Am I going to miss my flight?" And if we think about, when do we typically get sick in our lives, it's when we're tired and run down and stressed out. That's because our parasympathetic nervous system, that innervates our digestive tract, it also innervates our lymphatic system. So acknowledging that we can be stressed when we fly and trying to minimize that.

Christine Galione (29:08): The other thing is we might be carrying a heavy purse over our shoulder, possibly cutting off some of the lymph flow that's going up to lymph nodes in the neck or into the back. We're lifting that heavy suitcase on wheels, into the car, out of the car, up into the overhead bin, using our muscles, straining. So now we're kind of doing a rigorous, repetitive exercise, maybe not with great technique. And then when we get to the airport, the only thing they have is salty, processed high sodium foods. The sodium is a water retainer. So it's going to just start to take the water and keep it underneath our skin, which is going to increase the traffic. And everyone swells a little bit when they go on an airplane. The cabin decompresses. If you've ever watched a bag of chips, if you take a sealed bag of chips at takeoff, they're kind of squishy and there's some air in there. Once you get off, that bag is solid, because it's expanding.

Christine Galione (30:07): We all expand a little bit, but now we've taken a stressed system that isn't functioning as well as it should. We've eaten a bunch of salty food, which is causing more swelling. We've lifted something heavy that could possibly caused some muscle swelling and we've just naturally expanded a little bit.

Christine Galione (30:24): So we're adding a whole bunch of things on the flight. So what I tell my patients is control the things that you can control and you have to let go of the things you can't. So get to the airport a little bit earlier. So you're not stressed out. If you have a heavy suitcase, ask if someone can lift it overhead for you. So make sure you're hydrated a couple days ahead of time. Watch your salty food intake before the flight and keep moving, keep active. If you're sitting on the airplane, we've got lymph nodes in our neck, we can stimulate those by just doing side to side head turns or head tilts, the lymph nodes in our armpits, we can do shoulder shrugs, we can do little circles. We can take some deep breaths to get the lymph nodes in our gut. We can do little marching in our seat to get the lymph nodes in the groin. So there's things that we can do to keep our system moving, that's going to decrease the risk of flight induced lymphedema.

Kristen Vengler (31:17): And you're reminding me also that I can stimulate my lymph system by just doing those things, sitting in the car, sitting at my desk, while we're talking. I can be doing those things. And it's important to see a therapist and get the right treatment with lymphedema. But there's a lot of things that you can do at home to supplement that.

Eva Sheie (31:38): How did you even end up doing this, Christine? Tell us how you got here.

Christine Galione (31:43): I started 20 years ago in the acute care setting, because I initially thought I wanted to work with neuro patients, like head injury, stroke, traumatic brain injury. So I took a job at Scripps because it was a trauma hospital. And so I wanted to work in the ICU. But about, I think six to eight weeks into me starting the job, the person on our team who did the wound care tore his ACL and was out. And so they said we need someone to help with the wound care. And so I'm pretty sure they asked everyone else on the team and they said no. And then they got to me and I thought, gosh, I'm new and I do not want to seem like I am not a team player. So I'll do the wound training and I'll do the wound care.

Christine Galione (32:25): And so I started and just fell in love with it, just found it so fascinating and exciting. And so in doing that, a lot of our swollen leg patients had wounds. And it's really hard to heal a wound if the skin is being pulled apart, because the person is swollen. And so the lymphedema team came in and said, "Well, we're going to show you how to wrap for a wound healing because if you can take the pressure off of the skin and allow the skin to grow together, you'll heal the wound faster." And it worked beautifully. And I was like, wow, that's really cool. I want to know more about that. So it just lucked out that one of the lymphedema training schools, the person lives in Temecula. And so she was doing a six day advanced training for lymphedema and it was in San Diego.

Christine Galione (33:15): So I got to do this six day, 10 hour boot camp on lymphedema. And the more and more I did the lymphedema, the more and more I loved it. And so about four or five months after that, one of the lymphedema therapists went out on maternity leave and the outpatient department had said, "Hey, would you mind covering both?" And so I said, "Yeah, sure. I can pop back and forth." And I just loved the outpatient setting and getting to talk to people for 60 or 90 minutes. You really get to know them and they get to know you and you get to be a part of their journey for the long haul, where in acute care, you see them for three to five days and then they're off somewhere else. So I just loved seeing them improve over a period of time. And so I've been down there for about 16 years or so now, maybe 17. And so that's how I got here.

Kristen Vengler (34:10): So all the opportunities of people living their lives, getting their ACL done, having kids, all of that presented these opportunities for you to learn more and to step into those roles. That's awesome. And then you loved it, being in the dungeon.

Christine Galione (34:24): Yeah. When I came for my job interview 20 years ago, it was down in the basement and I kind of got lost. And Kristen, you'll know the hallways are a little convoluted. And I took this very long loopy way around. And I think I made the joke after my interview. I said, "Well, if I get the job, the good news is I won't need a gym membership." And he said, "Well, it's not really important that you know where we are, because we're moving any day now."

Kristen Vengler (34:48): In the next 20 years, or so.

Christine Galione (34:50): It's been 20 years and we've almost moved I think four times. But we have been promised, I think September-ish. So one of these days I'll get a window.

Kristen Vengler (35:02): I'm going to have to get you one of those, like a sticker kind of a thing that looks like a window and we'll put it above your two beds so like you're looking at the water or something like that.

Christine Galione (35:14): That would be awesome.

Kristen Vengler (35:16): Like a mural or something like that. And you can take it from room to room with you if you move for a day.

Eva Sheie (35:25): So Kristen, you had a referral to Christine, you didn't actually go find her on your own?

Kristen Vengler (35:31): Correct.

Eva Sheie (35:31): Is that the only way that people can get in to see you or can they actually schedule with you on their own?

Christine Galione (35:40): So in the State of California, we do have to work under an order from whether it's a doctor, nurse practitioner or physician's assistant or DO. Now, if someone wants to go more for lymphatic massage, more for keeping the system moving, there are plenty of wonderful licensed massage therapists that are also lymphedema certified. You don't need a prescription for that, but if you are going to use insurance and if there's a medical need, there needs to be an order.

Kristen Vengler (36:10): What I've found is that it's pretty easy when you have a mastectomy or when you've had breast cancer surgery. They'll pretty much write you whatever it is that they think that you need. Dr. Koka, I didn't have lymphedema, but she said this is something that could very well form so I want to get you in before it gets to that place. So just knowing that's an option for those of you out there who are facing breast surgery, lymph node, dissection, removal, it's out there. I hope that all this information has helped for people to not be afraid of lymphedema.

Christine Galione (36:44): Absolutely.

Eva Sheie (36:46): Christine, I know you have some images. We're going to put those in show notes. Do you want to just describe what we'll be looking at, if we decide to look at these illustrations that you've shared with us about what the lymph system looks like?

Christine Galione (37:00): Absolutely. All right. So the first one I'm going to send over is going to be the lymph drainage system. And so what it's looking at is kind of a schematic of the superficial lymphatics. And it's showing how not only superficial the system is, but how it's anchored right into the base of our skin. So that is number one, that's the lymph drainage system.

Christine Galione (37:24): Number two, I'll send over. It's just a map of the lymph nodes in the body. So we were talking about there's somewhere between six and 700 lymph nodes and the different areas of collection. This is going to show those areas. There's a third one, the closeup of the initial lymphatic and showing how it gets pulled on and how the bigger molecules go into the lymph and the teenier molecules go into the veins.

Kristen Vengler (37:48): Thank you so much, Christine for everything and the care you've given me and your time and your knowledge, is invaluable.

Christine Galione (37:58): Thank you. I enjoy it. Thank you guys for having me.

Eva Sheie (38:01): Thank you for listening to Breast Cancer Stories. To continue telling this story and helping others, we need your help. All podcasts require resources, and we have a team of people who produce it, there's costs involved and it takes time.

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Eva Sheie (39:15): Thanks for listening to Breast Cancer Stories. There's a link in the show notes with all of the resources mentioned on this episode and more info about how you can donate. If you're facing a breast cancer diagnosis and you want to tell your story on the podcast, send an email to I'm Eva Sheie, your host and executive producer. Production support for the show comes from Mary Ellen Clarkson, and our engineer is Daniel Croeser. Breast Cancer Stories is a production of The Axis,

Christine Galione, MSPT, CLT

Physical Therapist

Lymphedema specialist Christine Galione, MSPT, CLT is a physical therapist and expert lymphatic massage practitioner at Scripps Memorial La Jolla who has been helping breast cancer patients with lymphedema therapy since 2004.