Effects of neuromuscular warm-up on athletes’ change-of-direction performance and knee isokinetic muscle strength: a systematic review and meta-analysis

<h4>Background:</h4> Neuromuscular warm-up is a structured protocol containing at least three of the following exercise types: resistance, dynamic stability, core strength, plyometrics, and agility. Neuromuscular warm-up holds significant clinical value for enhancing athletic performance and reducing injury risk. However, current evidence remains limited regarding its effects on change-of-direction (COD) performance and knee isokinetic muscle strength—two physical qualities critically associated with performance outcomes and injury prevention in multidirectional sports. Furthermore, a comprehensive synthesis is lacking on how to tailor warm-up protocols to optimally improve these two interrelated domains. <h4>Objective: </h4>This review aims to: 1) evaluate the effects of neuromuscular warm-up on COD performance and knee isokinetic muscle strength, and 2) systematically analyze moderating effects of warm-up protocols (number of exercise, frequency, sets, repetitions, duration, and metrics), athlete level, and study designs (randomized vs. non-randomized trials). <h4>Methods:</h4> Searches were conducted in PubMed, Web of Science (Core Collection), Embase, and Scopus on 5 May 2025, and updated on 15 May 2025. Pooled effects for each outcome were summarized using standardized mean difference (Hedges’ g) through a three-level meta-analysis model, subgroup and regression analyses were used to explore moderators. The certainty of evidence was assessed using the GRADE approach. <h4>Results:</h4> From 25,251 records, 19 studies (n = 810) were included, with a mean PEDro score of 6.00 (high quality). Neuromuscular warm-up significantly improved COD performance (g = 0.46 [0.09, 0.82], I2-2 = 33.7%; I2-3 = 37.7%, Moderate GRADE) and knee isokinetic muscle strength (g = 0.72 [0.39, 1.04], I2-2 = 69.5%; I2-3 = 5.2%, High GRADE) versus controls (regular or dynamic warm-up). Meta-regression analysis indicated that sets in neuromuscular warm-up protocols significantly moderate COD performance. Subgroup analyses indicated that warm-up protocols (neuromuscular warm-up frequency and metrics), athlete levels, and study designs significantly influenced both COD performance and knee isokinetic muscle strength (p < 0.05). <h4>Conclusion: </h4>Neuromuscular warm-up significantly enhances COD performance and knee isokinetic muscle strength compared to the control group, moderated by warm-up protocols (frequency, sets, and metrics), athlete level, and study designs. <h4>Systematic Review Registration:</h4> This study is registered with ClinicalTrials.gov as CRD420251046324.