BACKGROUND AND OBJECTIVES: Negative-pressure wound therapy (NPWT) expedites tissue repair, yet functional recovery depends on adjunct rehabilitation. Evidence from high-resource settings is difficult to translate to Romanian county hospitals, where advanced devices are scarce. The objective of this study is to determine whether two tiers of low-technology, therapist-delivered exercise improve mobility, oedema resolution, pain and quality-of-life (QoL) beyond NPWT alone in adults with acute lower-limb wounds. METHODS: A single-centre, prospective observational study (January 2021-June 2024) enrolled 92 patients and randomised them unevenly into: Group A, NPWT only (n = 39); Group B, NPWT plus routine physiotherapy (n = 33); Group C, NPWT plus enhanced manual programme (n = 20). All received -125 mmHg continuous suction; rehabilitation started 48 h post-operation. Primary outcomes were ankle dorsiflexion and knee flexion at 12 weeks. Secondary outcomes included calf circumference, ultrasound oedema depth, Manual Muscle Testing (MMT), pain (VAS), analgesic use and SF-36 domains through 24 weeks. RESULTS: Baseline characteristics were similar (p > 0.40). At 12 weeks dorsiflexion reached 20.1 +/- 1.8degree in Group C, surpassing Group B (18.4 +/- 2.1degree; p = 0.004) and Group A (16.0 +/- 2.3degree; p < 0.001). Knee flexion followed the same gradient (140.8 +/- 3.2degree, 137.6 +/- 3.4degree, 133.4 +/- 3.8degree respectively). Oedema depth fell fastest in Group C (0.4 +/- 0.2 mm by day 42) versus B (0.6 +/- 0.2 mm) and A (0.8 +/- 0.3 mm). Week-12 MMT grade >= 4.5 was attained by 95% of Group C, 85% of B and 72% of A (chi2 10.9, p = 0.004). VAS pain fell more steeply with each rehabilitation layer, paralleled by a stepwise decline in daily tramadol. All SF-36 domains were highest in Group C at 24 weeks (Physical Function 88.7 +/- 4.8 versus 85.1 +/- 5.4 versus 78.2 +/- 5.9; p < 0.001). Mobility correlated positively with QoL (r 0.66) and inversely with pain and oedema. CONCLUSIONS: In a resource-constrained Romanian setting, adding structured manual physiotherapy to NPWT produced meaningful functional and patient-centred gains, while an enhanced programme incorporating daily PNF and elastic-band strengthening delivered the largest observed benefit. These findings justify prioritising therapist-led interventions even where sophisticated equipment is unavailable.

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