Progressive respiratory muscle weakness in DMD leads to a gradual reduction in lung volumes, ineffective cough, and increasing risk of respiratory complications. With disease progression, patients ultimately develop chronic respiratory insufficiency requiring ventilatory support. Because both pulmonary function and ventilatory therapy parameters change over time and may not be fully captured during periodic clinic visits, respiratory care has become an important focus of remote monitoring approaches in DMD.

Pulmonary function testing represents the primary clinical method for quantifying respiratory decline in DMD. Standards of care recommend testing from approximately 5 to 6 years of age, with reassessment every 6 to 12 months depending on disease stage [2]. However, clinic-based spirometry provides only episodic snapshots of respiratory function and may fail to capture short-term fluctuations in respiratory status. This gap has driven the development of home respiratory monitoring technologies.

One of the earliest examples was the use of portable electronic peak flow meters during the Duchenne Muscular Dystrophy Long-term Idebenone Study (DELOS) trial, in which boys with DMD performed daily peak expiratory flow recordings at home, with the data downloaded during scheduled clinic visits [15]. Although not connected in real time, the study demonstrated both feasibility and patient adherence to home pulmonary monitoring.

More advanced home spirometry systems were evaluated in the e-PULMoDMD (e-Monitoring of Pulmonary Function in Patients With Duchenne Muscular Dystrophy at Home) study using the AioCare spirometer linked to a smartphone app [16,17]. These platforms enabled home measurement of forced vital capacity and forced expiratory volume in 1 second, provided step-by-step instructions, and delivered immediate feedback through graphical displays of spirometry curves. Some patients perceived daily recordings as a form of respiratory exercise, suggesting an additional motivational component [17]. Available evidence for home spirometry in DMD is primarily derived from small feasibility and pilot studies typically involving limited patient cohorts and short follow-up periods. While these studies consistently demonstrate technical feasibility and patient adherence, they provide limited data on clinical outcomes or long-term impact on disease management.

With disease progression, many patients with DMD require noninvasive ventilation (NIV) and, less frequently, invasive mechanical ventilation. Both modalities require ongoing monitoring to ensure adequate ventilation, comfort, and adherence. Early ventilator systems allowed for only manual data extraction [18], whereas modern platforms offer internal or external modems capable of transmitting use time, leak values, respiratory rate, tidal volume, inspiratory-to-expiratory ratios, and longitudinal trends of key parameters [19].

Telemonitoring has been associated with clinical benefits in broader neuromuscular populations; however, evidence specific to DMD remains limited, and the extent to which these findings translate to DMD care is uncertain. Bertini et al [18] demonstrated that weekly remote review combined with 24-hour support reduced emergency visits and hospital admissions among ventilated children. Trucco et al [19] reported high caregiver satisfaction and fewer hospital presentations in children using NIV, including those with DMD. During the COVID-19 pandemic, Onofri et al [20] showed that remote interpretation and adjustment of ventilatory parameters were feasible, and none of the telemonitored children required urgent admission. Additional reports from broader neuromuscular populations describe improved clinical stability, reduced hospitalization rates, and enhanced caregiver confidence associated with respiratory telemonitoring [7,10]. Despite these benefits, routine implementation remains limited by infrastructural, regulatory, and reimbursement barriers. Evidence supporting ventilator-based telemonitoring is stronger but largely extrapolated from broader neuromuscular populations rather than DMD-specific cohorts. Reported benefits include reduced hospitalizations and improved caregiver confidence; however, data specific to DMD remain limited and heterogeneous.

Respiratory remote monitoring in DMD includes home spirometry and telemonitoring integrated with ventilatory support. These approaches allow for the collection of longitudinal data on pulmonary function and therapy use outside routine clinic visits, although current evidence is based mainly on small studies and feasibility reports.

Cardiac involvement in DMD most commonly manifests as dilated cardiomyopathy and rhythm disturbances and represents a major source of morbidity and mortality [2]. Cardiac status may deteriorate gradually and remain clinically silent, which makes regular surveillance using echocardiography, electrocardiography, cardiac biomarkers, and cardiac magnetic resonance imaging a key component of care [3]. Because conventional follow-up relies on periodic, center-based investigations, dynamic changes in ventricular function or intermittent arrhythmias may not be fully captured between visits, supporting interest in remote and device-based cardiac monitoring approaches.

In more advanced stages, management extends beyond surveillance and includes cardioprotective pharmacotherapy as well as, in selected cases, implantable cardiac devices. Therefore, monitoring may occur both through dedicated wearable systems and as an integrated function of therapeutic devices, linking remote observation with active treatment.

Noninvasive cardiac telemonitoring is most commonly delivered through wearable sensors and ambulatory rhythm monitoring systems, often incorporated within broader telehealth models. Wearable heart rate devices, chest straps, patch-based electrocardiographic monitors, and consumer-grade smartwatches have demonstrated feasibility for rhythm screening and symptom correlation in pediatric and chronic disease populations [8]. These technologies enable intermittent or continuous recording of heart rate and rhythm outside the clinical setting and illustrate the technical feasibility of long-term rhythm surveillance.

Experience with ambulatory rhythm monitoring in DMD also includes conventional Holter-based assessments reported in small observational studies [48]. Nevertheless, the use of wearable or ambulatory rhythm monitoring specifically in DMD remains limited. Available studies are few, involve small sample sizes, and lack definitive evidence linking remote rhythm surveillance with changes in management or clinical outcomes. As a result, wearable cardiac monitoring in DMD currently represents a developing component of digital health rather than an established standard. Current evidence for wearable cardiac monitoring in DMD remains limited and is derived mainly from small observational studies and feasibility reports.

In more advanced stages of cardiomyopathy, implantable cardioverter defibrillators (ICDs) and, less frequently, pacemakers or cardiac resynchronization therapy systems may be considered. Although primarily therapeutic, these devices also generate continuous monitoring data, blurring the boundary between treatment and remote surveillance. Published experience with pacemakers, cardiac resynchronization therapy, and ICDs in DMD consists mainly of small case series and retrospective reports, reflecting cautious use and uncertainty regarding long-term benefit in this population [21-24]. Additional reports describe ICD implantation in selected patients, with automatic rhythm surveillance and event logging as inherent device functions, although the structured use of remotely transmitted data in DMD care has not been systematically evaluated [25,26].

Left ventricular assist device implantation in DMD has been described only in isolated case reports and small series, involving devices such as HeartMate II, HeartWare, and Jarvik systems [25-28]. These cases highlight complex ethical and practical considerations in patients with advanced neuromuscular disability and respiratory compromise. Although left ventricular assist device controllers technically allow for remote review of device alarms and selected performance parameters, there are no data confirming their integrated use within structured remote cardiac follow-up in DMD. Evidence regarding implantable cardiac devices in DMD is based primarily on case series and retrospective analyses. While these devices provide continuous monitoring capabilities, their role in structured remote monitoring and long-term outcome improvement in DMD remains insufficiently defined.

Cardiac parameters have also been monitored indirectly within multisystem telemedicine programs. Trucco et al [19] reported that telehealth follow-up originally implemented for NIV in children, including those with DMD, facilitated remote triage of both respiratory and cardiac symptoms and was associated with fewer emergency consultations. These findings suggest that telecardiology in DMD may be particularly effective when embedded within integrated, multidisciplinary monitoring models rather than functioning as a stand-alone tool.

Cardiac remote monitoring in DMD currently involves wearable or ambulatory rhythm surveillance, data generated by implantable therapeutic devices, and cardiac parameters captured within broader telehealth programs. Although a range of technologies is available, their structured clinical use in DMD remains limited. The evidence base consists primarily of small case series, feasibility studies, and data extrapolated from broader cardiology populations, which limits the strength of conclusions regarding clinical impact in DMD.

Progressive loss of motor function is a defining feature of DMD and represents a key target for digital and device-based monitoring approaches. Functional decline evolves gradually and may fluctuate with fatigue, intercurrent illness, or changes in therapy. Traditional clinical assessments—such as timed tests, walking tests, or structured upper-limb scales—provide standardized but episodic measurements obtained under supervised conditions and may not fully reflect how patients function in everyday environments. These characteristics make functional performance a natural target for digital technologies that enable repeated observation, objective quantification, and technology-supported rehabilitation.

Wearable sensor technologies have enabled continuous or repeated measurement of real-world physical activity in individuals with DMD. Accelerometers, actigraphy devices, and magneto-inertial sensor systems have been used to quantify daily movement patterns, walking behavior, and upper-limb use outside the clinic [29-32]. These approaches shift assessment from performance in a controlled test toward observation of habitual activity in natural settings.

Subsequent studies have extended these methods to community walking and upper-extremity activity, demonstrating feasibility and correlations between sensor-derived metrics and established functional measures [33,34]. Broader activity profiling—including in nonambulant individuals—has shown that digital activity metrics can capture dimensions of participation and movement not represented by traditional ambulation-focused scales [35,36]. Associations between physical activity patterns and physiological parameters further suggest that movement data may reflect overall clinical status [37].

Despite this promise, barriers remain to routine clinical adoption. Long-term adherence, variability in device placement, and the need for clinically interpretable metrics pose challenges. From a regulatory perspective, the qualification of wearable-derived end points in DMD is still evolving, with ongoing discussion regarding validity, reliability, and clinical meaning of digital mobility outcomes. Although wearable technologies enable detailed characterization of real-world activity, the evidence remains largely exploratory. Studies are typically small and heterogeneous, and the relationship between digital activity metrics and clinically meaningful outcomes in DMD is not yet fully established.

While digital rehabilitation in DMD has largely focused on motor function, technology-assisted rehabilitation of the respiratory system has been explored far less frequently. An early example is the computerized respiratory muscle training described by Vilozni et al [38] in which visual computer feedback was used to guide breathing exercises in children with DMD. Although this approach was not based on immersive virtual environments and was not designed for remote use, it illustrates that digital tools have also been applied to support functional training of respiratory muscles. However, compared with the expanding field of interactive motor rehabilitation platforms, digital respiratory rehabilitation remains markedly underdeveloped.

Beyond passive monitoring, digital technologies are also used to actively support rehabilitation. Earlier exploratory platforms further illustrate the feasibility of immersive or augmented environments in neuromuscular populations [39,40]. Virtual reality (VR), game-based platforms, and interactive computer or smartphone systems combine therapeutic exercises with real-time feedback and data capture. In DMD, these approaches have been explored mainly for upper-limb training and engagement in individuals with limited mobility [41-43].

Controlled and crossover studies have reported that VR-based or interactive training can improve task performance, support motor learning, enhance motivation, and increase adherence to therapeutic activities [44,45,49]. These systems often record performance parameters such as movement accuracy, task completion, and interaction patterns, generating structured data alongside therapy. A systematic review highlights the growing but still heterogeneous evidence base for VR technologies in DMD [50].

However, most VR and interactive systems are not yet calibrated against validated clinical end points, and study sizes remain small. A key future direction is linking digitally captured performance data with established functional scales and clinically meaningful thresholds, as well as integrating remote supervision and data sharing with rehabilitation teams. Evidence supporting virtual and interactive rehabilitation in DMD is growing but remains limited by small sample sizes, variability in study design, and lack of standardized outcome measures. As a result, translation of these approaches into routine clinical practice is still constrained.

Digital approaches to rehabilitation in DMD encompass 2 complementary directions: wearable systems that capture real-world movement and activity and interactive platforms that combine therapy with structured data generation. Together, they extend functional assessment beyond clinic-based testing and provide insights into everyday performance and engagement. In contrast, technology-assisted respiratory rehabilitation has received limited attention, highlighting an imbalance in the development of digital therapeutic strategies across organ systems.