Remote supervised exercise- and physical activity-based rehabilitation for post-stroke depression, anxiety, and quality of life: a systematic review, evidence map, and exploratory quantitative synthesis

Background Depression, anxiety, and reduced quality of life are common after stroke and may interfere with rehabilitation engagement and long-term recovery. Remote supervision can support home-based exercise or physical activity, but the available programs are complex packages that may also include coaching, caregiver involvement, education, and psychological support. We aimed to synthesize randomized evidence on depression, anxiety, and quality of life after remotely supervised exercise- or physical activity-based stroke rehabilitation, accounting for comparator type and co-interventions. Methods This systematic review was registered in PROSPERO (CRD420261394314) and reported according to PRISMA 2020. PubMed/MEDLINE, Web of Science, SPORTDiscus, Cochrane Library, Embase, and Scopus were searched from inception to 1 March 2026. Randomized studies of remotely supervised exercise- or physical activity-based rehabilitation after ischemic or hemorrhagic stroke were eligible if depression, anxiety, or quality-of-life outcomes were extractable. Risk of bias was assessed using RoB 2, certainty was evaluated using GRADE, and a co-intervention sensitivity analysis examined the evidence remaining after exclusion of interventions with explicit psychological support. Results Six randomized studies involving 483 participants were included. Interventions, comparators, outcome instruments, and study designs were heterogeneous, precluding a primary pooled meta-analysis. The only directly analyzable depression effect against standard care came from Sun et al., a 12-week multidisciplinary telerehabilitation program that included online psychological counseling; the aligned Hedges g was 0.93 (95% CI 0.64 to 1.22), conventionally large, but certainty was very low. After this trial was excluded, no directly analyzable depression effect against standard care remained. Active-vs-active depression or distress findings did not establish superiority. Quality-of-life signals varied across instruments and comparators; no separable patient anxiety effect was available. Conclusion The included evidence concerns complex remote rehabilitation packages rather than exercise alone. A possible depression benefit is supported principally by one trial with a psychological-support co-intervention and is therefore fragile. Remote programs should not be regarded as stand-alone treatments for post-stroke depression or anxiety. Confirmatory trials should recruit or stratify participants by baseline psychiatric symptoms, prespecify psychiatric outcomes, and separate exercise from psychological and implementation components. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261394314 , identifier CRD420261394314.