Hope through Rehabilitation & Research
Instructor, Biostatistics and Epidemiology
Weill Cornell Medical College
The concepts of epidemiology are at the core of public health and draw from the disciplines of biology, logic, statistics and scientific philosophy (KJ Rothman). Simply put, epidemiology is the study of disease determinants and of the associated measures for controlling incidence and prevalence of illness. While it’s true that epidemiologists use statistical methods to assess association, they are also trained to address additional topics such as hypothesis formulation, disease causation, study design, randomization, and measurement of causal effects, random error and bias. These methods are used to target the following overarching objectives in the study of human disease: 1) identify the etiology and risk factors for disease; 2) define the incidence, prevalence, natural history and prognosis of disease; 3) evaluate and compare existing and new preventive and therapeutic measures to control disease; 4) provide information to develop guidelines of clinical practice; 5) provide the foundation for making policy and regulatory decisions relating to environmental or social determinants of disease (L. Gordis). Here at Burke, I work with clinicians and scientists who are defining the cutting edge of neurological repair and regeneration to translate research discoveries into clinically useful practices in the field of neurological rehabilitation. I utilize the methods and concepts of epidemiology to design and conduct studies that aim to assist patients with neurological disease and injury reach their maximum recovery potential.
B.S. Health Science: 1997, State University of New York at Cortland
MPH, Public Health: 2005, University of Rochester
Ph.D., Epidemiology: 2009, University of Rochester
Gary E. Gibson, Joseph A. Hirsch, Rosanna T. Cirio, Barry D. Jordan, Pasquale Fonzetti, Jessica Elder. “Abnormal thiamine-dependent processes in Alzheimer's Disease. Lessons from diabetes.” This chapter was published in the journal Molecular and Cellular Neuroscience.
Timothy RP, Fisher SG, Elder JL, Winters PC, Beckett W, Tacci J, Sloand JA. Increased cardiovascular risk associated with reduced kidney function. American Journal of Nephrology. 2009; 29: 620-625.
Wexler O, Yoder SR, Elder JL, Mackin ML, Chen L, Mixon L, Schwartz RG. Effect of gender on cardiovascular risk stratification with ECG gated SPECT left ventricular volume indices and ejection fraction. Journal of Nuclear Cardiology. 2009; 16: 28-37.
Stroke is the leading cause of disability and impacts over 750,000 people per year in the United States. Despite this, we currently don’t have a thorough understanding of why some patients experience a quick and full recovery while others are left with permanent and severe impairments.
A number of groups, including our own, are looking for genotype and phenotype correlations that might better predict outcomes among stroke patients admitted to a rehabilitation unit. Since environmental factors influence gene expression and their potential to influence the trajectory of stroke recovery, we have decided to focus on epigenetics. Strictly defined, epigenetics refers to heritable changes in phenotype that are not directly related to changes in genetic sequence. Within the context of stroke recovery it is our hope to understand gene expression patterning via examining epigenetic modifications in blood borne cells.
The central aim of this study is to determine if there are epigenetic predictors in patient blood samples that add substantial explanatory information to existing clinical predictors for defining the variability in recovery among stroke patients. Discovering such predictors will 1) allow physicians to give a more reliable prognosis to stroke patients and their families; 2) inform individual rehabilitation strategies; 3) direct research aims for future therapeutic discoveries; and 4) aid in the prescription of modifiable behaviors or environmental exposures that may modulate recovery patterns.
We will recruit a population of severely impaired ischemic stroke patients admitted to inpatient rehabilitation, develop a comprehensive library of clinical, demographic and biological predictors of recovery that have previously been shown to influence heterogeneity in functional outcome, and track their course of recovery. Additionally, we will undertake a novel investigation of specific epigenetic mechanisms such as DNA methylation, histone modifications, and non-coding RNAs (i.e., miRNAs) and assess their association with neurological recovery.
Developing a human epigenetic research infrastructure, the first of its kind, will compliment current genetic studies ongoing at BMRI and our associated Rehabilitation Hospital. We will use this infrastructure to assess the association between non-sequence related DNA modifications and clinical phenotypes to provide pivotal information in the search for mechanisms that influence neurorepair. Successful execution of this study will involve the use of existing resources including our team of scientists, clinicians and researchers who have a successful track record for hypothesis generation, study design, patient recruitment, data processing and analysis and dissemination of results.
Motor skill training and transcranial direct current stimulation (tDCS) have been shown to independently alter cortical excitability and enhance motor function in humans. The interaction of these two techniques is currently under investigation in multiple laboratories. We have previously shown that the timing of tDCS application has functional significance; tDCS applied prior to training can be beneficial for voluntary behavior, and tDCS may not simply be additive to training effects but may change the nature of the training effect. We have separately reported in a randomized-controlled clinical trial, that upper limb robotic training alone over 12 weeks can improve clinical function of chronic stroke patients. Based on our results with tDCS and robotic training, we hypothesize that the same repeated sessions of robotic training, but preceded by tDCS, would lead to a sustained and functional change greater than robotic training alone. In this study we will recruit 66 stable, chronic, stroke patients who will be randomized to receive sham or real tDCS prior to robotic upper limb training. Three levels of change will be assessed: (i) clinical, (ii) kinematic, and (iii) neurophysiologic. We will determine if clinical function can be improved and sustained with tDCS-robotic training, the precise kinematic aspects of movement, and cortical physiology changes that underlie functional improvements. The findings from this study will enhance our knowledge of how robotic training combined with temporally-specific brain stimulation influences plasticity and ultimately, has the potential to inform rehabilitation strategies that can maximize functional recovery.
Dr. Elder provides scientists and physicians epidemiological support to help turn their ideas into fundable, rigorously designed projects that will yield meaningful and valid conclusions. She is currently an Investigator on several submitted and awarded grants including interventional studies in the areas of Alzheimer’s Disease, spinal cord injury and stroke. Dr. Elder also participates in retrospective research studies in the areas of stroke and traumatic brain injury.
Statistical Methods for Observational Studies & Research Synthesis Weill Cornell Medical College, 2012
Principals and Practice of Clinical Research Harvard Medical School Department of Continuing Education, Sao Paolo, Brazil, October 2011
Epigenetic Predictors of Stroke Recovery
Funded by the Dana Foundation
Co-PI: Rajiv Ratan, MD, PhD; Jessica Elder, PhD
Transcranial Direct Current Stimulation and Robotic Training in Chronic Stroke
Ro1 Funded by the National Institute Health
PI: Dylan Edwards, PT, PhD (role: C0-I)