Effects of Neuromuscular Warm-Up on Athletes' Change-of-Direction Performance and Knee Isokinetic Muscle Strength: A Systematic Review and Meta-Analysis

Chenwen Zhu^1*Yunfei Lu¹Meiling Tao²Tianyue Yin¹Jiuzhang Li³Steve Thompson⁴Nan Gu^1*

• ¹China Table Tennis College, Shanghai University of Sport, Shanghai, China
• ²Shanghai University of Sport School of Athletic Performance, Shanghai, China
• ³The University of Sydney, Sydney, Australia
• ⁴Sheffield Hallam University, Sheffield, United Kingdom

ABSTRACT Background: 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. Objective: 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). Methods: Searches were conducted in PubMed, Web of Science (Core Collection), Embase, and Scopus on May 5, 2025, and updated on May 15, 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. Results: 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). Conclusion: 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.