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Evaluation and Diagnosis of Wrist Pain: A Case-Based Approach

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Patients with wrist pain commonly present with an acute injury or spontaneous onset of pain without a definite traumatic event. A fall onto an outstretched hand can lead to a scaphoid fracture, which is the most commonly fractured carpal bone. Conventional radiography alone can miss up to 30 percent of scaphoid fractures. Specialized views (e.g., posteroanterior in ulnar deviation, pronated oblique) and repeat radiography in 10 to 14 days can improve sensitivity for scaphoid fractures. If a suspected scaphoid fracture cannot be confirmed with plain radiography, a bone scan or magnetic resonance imaging can be used. Subacute or chronic wrist pain usually develops gradually with or without a prior traumatic event. In these cases, the differential diagnosis is wide and includes tendinopathy and nerve entrapment. Overuse of the muscles of the forearm and wrist may lead to tendinopathy. Radial pain involving mostly the first extensor compartment is commonly de Quervain tenosynovitis. The diagnosis is based on history and examination findings of a positive Finkelstein test and a negative grind test. Nerve entrapment at the wrist presents with pain and also with sensory and sometimes motor symptoms. In ulnar neuropathies of the wrist, the typical presentation is wrist discomfort with sensory changes in the fourth and fifth digits. Activities that involve repetitive or prolonged wrist extension, such as cycling, karate, and baseball (specifically catchers), may increase the risk of ulnar neuropathy. Electrodiagnostic tests identify the area of nerve entrapment and the extent of the pathology.

Also Read: Orthopedic Doctor: Types Of Fractures

Musculoskeletal problems are responsible for up to 20 percent of all visits to primary care offices in the United States. 1  Family physicians are often the first to evaluate and treat wrist pain. Wrist pain is traditionally classified as acute pain caused by a specific injury or as subacute/chronic pain not caused by a traumatic event (Tables 1 and 2). Injuries that cause acute pain may result in contusions, fractures, ligament sprains or tears, and instability. Subacute or chronic pain may result from overuse, have neurologic or systemic causes, or be a sequela from an old injury. Patients with these injuries may have a history of repetitive wrist movement, either occupationally or recreationally. The addition of sensory disturbances, such as numbness or tingling, points to nerve involvement.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.xml.

History and physical examination lead to the correct diagnosis in most cases. The location, nature, timing, and quality of the pain are important clues for narrowing the differential diagnosis. In acute wrist injuries, plain radiography should be obtained with anteroposterior, lateral, and oblique views. When the diagnosis remains unclear, further imaging, such as bone scan, ultrasonography, computed tomography, or magnetic resonance imaging (MRI), may help identify the cause. Because nontraumatic wrist pain has a wide differential diagnosis, the patient history should include a review of systems with neurologic or constitutional symptoms, as well as a social history of vocational and recreational activities. The following case studies discuss the background and presentation of three causes of wrist pain, as well as diagnostic tests and strategies.

Case 1. Scaphoid Fracture

A 21-year-old man presents with dorsal left wrist pain after falling onto his outstretched hand while inline skating. He noted immediate swelling and painful wrist extension. Physical examination reveals soft tissue swelling with limited motion, mostly in extension, secondary to pain. There is bony tenderness along the distal radius as well as the anatomic snuff box. His sensory and vascular examination results are unremarkable.

BACKGROUND

The wrist comprises eight carpal bones (Figure 12), but only the lunate and scaphoid articulate with the radius and absorb significant impact during a fall onto an outstretched hand. The scaphoid is the most commonly fractured carpal bone. The primary vascular supply to the scaphoid originates distally from retrograde branches of the distal radial artery, making the proximal pole of the scaphoid relatively avascular and at higher risk of nonunion and avascular necrosis. Fractures of the proximal and distal portions of the scaphoid each account for 20 percent of scaphoid fractures, and the middle portion accounts for the remaining 60 percent.

 

Figure 1.

The bones of the wrist.

Reprinted with permission from Daniels JM II, Zook EG, Lynch JM. Hand and wrist injuries: part I. Nonemergent evaluation. Am Fam Physician. 2004;69(8):1941.

The peak incidence of scaphoid fractures occurs at about 15 years of age. Because of the weakness of the distal radius compared with the scaphoid, scaphoid fractures are not common in older persons. In young children, the supportive cartilage surrounding the ossific nucleus of the immature scaphoid creates protection, making physeal injuries of the radius more common.

Also Read: Orthopedic Doctors In Florida: Facts About A Proximal Humerus Fracture

PRESENTATION

The typical history of a patient with a scaphoid fracture is a fall onto an outstretched hand with the wrist dorsiflexed and radially deviated. Most patients with scaphoid fractures present shortly after a fall, but in some cases, the initial pain improves, causing a delayed presentation.

Physical examination may reveal a swollen wrist. Tenderness is usually located dorsally around the distal radius. Patients may have painful wrist extension and loss of grip strength if they present a few days after the injury.

There are no reliable clinical tests to rule out a scaphoid fracture. Swelling of the anatomic snuff box (Figure 2) increases the likelihood of a scaphoid facture. The combination of snuff box swelling, scaphoid tubercle tenderness, and pain with axial pressure on the first metacarpal bone has a sensitivity of approximately 100 percent. However, the specificity of each test is 9, 30, and 48 percent, respectively. Diminished grip strength compared with the contralateral side increases the positive predictive value for a scaphoid fracture. The differential diagnosis of a suspected scaphoid fracture is listed in Table 3.

Figure 2.

Anatomic snuffbox. The scaphoid is located below the snuffbox.

Reprinted with permission from Phillips TG, Reibach AM, Slomiany WP. Diagnosis and management of scaphoid fractures. Am Fam Physician. 2004;70(5):880.

DIAGNOSTIC TESTS

Conventional radiography (anteroposterior, lateral, and oblique views) alone can miss up to 30 percent of scaphoid fractures. Based on retrospective studies, sensitivity improves if additional views are added (i.e., posteroanterior in ulnar deviation, pronated oblique, and supinated oblique). In many cases, repeat radiography is needed in 10 to 14 days to observe sclerosis, which indicates a healing fracture.

If the diagnosis cannot be confirmed with plain radiography, a bone scan or MRI can be performed. Bone scan has a sensitivity near 100 percent but produces false-positive results up to 25 percent of the time. MRI within one day after trauma has a sensitivity of 80 percent, but late examination (more than 10 days after injury) has a sensitivity and specificity comparable to bone scan.

DIAGNOSTIC STRATEGY

If a scaphoid fracture is suspected based on history and physical examination, plain radiography should be performed, including specialized views such as a posteroanterior in ulnar deviation and a pronated oblique. If radiography is negative for fracture but clinical suspicion is high, the wrist should be protected in a thumb spica cast with the option of repeat plain radiography in 10 to 14 days or a bone scan one to two days after injury. If repeat plain radiography is negative but wrist pain persists, MRI should be performed to clarify the diagnosis.

Case 2. Ulnar Neuropathy

A 39-year-old right-handed woman presents with a four-week history of wrist pain and numbness and tingling in her right hand. There is no history of trauma or injury to the neck, elbow, or wrist. She works mostly at a desk job but has not had any changes in her work schedule. Physical examination of the wrist reveals no soft tissue swelling, muscle atrophy, or skin changes. She has painful wrist extension, as well as reproduction of the tingling in her fifth finger with tapping over the pisiform. Grip strength is normal and no other bony tenderness is appreciated.

BACKGROUND

The ulnar nerve originates from the C8 and T1 nerve roots (Figure 3), and extends from the medial cord of the brachial plexus through the axilla, innervating the muscles of the forearm and the hand. Proximal to the wrist, dorsal and palmar cutaneous branches split off, whereas the rest of the nerve courses through the Guyon canal (Figure 4) to the palmar surface of the hand. This triangular canal is bordered medially by the pisiform, laterally by the hamate, anteriorly by the tendon of the flexor carpi ulnaris, and posteriorly by the transverse carpal ligament. In the canal, the ulnar nerve splits to a superficial sensory branch, which supplies sensation to the hypothenar eminence, and to a deep motor branch that innervates the hypothenar muscles, adductor pollicis, and flexor pollicis brevis. The ulnar nerve may be compressed anywhere in the Guyon canal, causing motor, sensory, or mixed deficits. Compression is usually caused by ganglion cysts or repetitive trauma.

Ulnar nerve entrapment is the second most common neuropathy of the upper extremity, surpassed only by median nerve entrapment (i.e., carpal tunnel syndrome). Although the true incidence of ulnar neuropathy at the wrist is not well documented, it is accepted to be the second most common site after compression at the elbow. Ulnar neuropathies are slightly more common in men than in women. Peak incidence is in men older than 35 years.

PRESENTATION

The typical presentation in ulnar neuropathy is wrist discomfort with sensory changes in the fourth and fifth digits. Grip weakness may be present in chronic cases. History usually reveals no specific injury. Activities that involve repetitive or prolonged wrist extension, such as cycling, karate, and baseball (specifically catchers) may increase the risk of ulnar neuropathy.

Physical examination of a patient presenting with these neurologic symptoms should include cervical spine, shoulder, and elbow examinations to rule out a proximal lesion. Reproduction of pain on neck movement could indicate cervical disk disease; pain with shoulder motion could indicate a brachial plexus problem; and reproduction of symptoms with compression of the nerve at the ulnar groove could indicate compression at the elbow. Compression of the ulnar nerve at the Guyon canal should cause weakness of the hypothenar muscles innervated by the deep motor branch and sensory disturbances of the fifth digit innervated by the superficial sensory branch.

Clinical tests include a positive Tinel sign on percussion of the ulnar nerve over the Guyon canal, as well as a positive Phalen sign (maximum passive flexion of the wrist for more than one minute) with paresthesias in the fourth and fifth fingers. Unlike in carpal tunnel syndrome, sensitivity and specificity of these tests for ulnar neuropathy at the wrist are not known. The differential diagnosis of suspected ulnar neuropathy at the wrist is listed in Table 4.

DIAGNOSTIC TESTS

Plain radiography evaluates wrist anatomy well, and can identify fractures, dislocations, or soft tissue masses that may have led to nerve compression.

Ultrasonography of peripheral nerves is helpful in identifying compressive etiologies of nerve injury and in visualizing structural nerve changes. It is noninvasive, relatively inexpensive, and well tolerated by patients.

Electromyography and nerve conduction studies can be helpful in identifying the area of entrapment and documenting the extent of the pathology. Motor and sensory conduction velocities are more useful in acute entrapments, whereas electromyography is a better choice for chronic neuropathies because it shows axonal degeneration more clearly. The sensitivity and specificity of these electrodiagnostic tests in the primary care setting are unknown because existing studies are limited to a small number of patients with known neuropathy.

MRI can detect abnormalities of the ulnar nerve, flexor tendons, vascular structures, and the transverse carpal ligament around the Guyon canal. Neurogenic edema can be seen as early as 24 to 48 hours after denervation compared with electromyography, in which changes after denervation are not seen for one to three weeks. Imaging criteria for neuropathy on MRI are not well defined, and several studies have found MRI abnormalities in healthy, asymptomatic patients.

DIAGNOSTIC STRATEGY

If ulnar neuropathy is suspected, plain radiography should be ordered first. If no obvious mass or lesion is found, electrodiagnostic tests should be ordered to localize the lesion, measure its severity, and aid in the prognosis. In the setting of inconclusive or nonlocalizing electrodiagnostic test results, ultrasonography or MRI may be useful.

Case 3. De Quervain Tenosynovitis

A 31-year-old woman presents with several months of worsening radial left wrist pain that started insidiously. She denies any specific trauma. She has no numbness or tingling in the wrist, hand, or fingers. Her pain worsens with gripping and grasping, and with picking up her nine-month-old daughter. Physical examination reveals no discoloration and minimal soft tissue swelling along the radial styloid and anatomic snuff box. There is soft tissue tenderness about the anatomic snuff box and radial styloid. She has limited motion of the thumb, with pain mostly in extension and abduction. Her sensory and vascular examinations are unremarkable.

BACKGROUND

Two major dorsal tendons of the thumb are involved: the extensor pollicis brevis and the abductor pollicis longus (Figure 5). [ corrected] These tendons comprise the lateral border of the anatomic snuffbox, with the extensor pollicis longus medially and the scaphoid bone at the bottom. The two tendons have similar function in bringing the thumb into radial abduction. These tendons run in a synovial sheath in the first extensor compartment of the hand. Inflammatory changes in the sheath and tendons result in a tenosynovitis. Recurrent or persistent inflammation may result in stenosing tenosynovitis.

PRESENTATION

The typical presentation includes subacute radial wrist pain at the thumb base and into the distal radius. In retrospect, patients may identify a new or repetitive hand-based activity as the cause, but the etiology often is idiopathic. De Quervain tenosynovitis is more common in women, particularly those 30 to 50 years of age. New mothers are especially noted to have this problem from picking up a child.

Physical examination may reveal a minimally swollen wrist. Tenderness is usually located over the radial tubercle and sometimes around the soft tissues of the anatomic snuff box. Thumb motion is invariably painful. Neurovascular examination should be unremarkable. The Finkelstein test is confirmatory because it has good sensitivity and specificity. It is performed by making a fist over the thumb and then moving the hand into ulnar deviation, which passively stretches the thumb tendons over the radial styloid A grind test of the thumb, which is performed by axial compression and slight rotation of the metacarpophalangeal joint, should be negative in those with de Quervain tenosynovitis but positive in those with first carpometacarpal osteoarthritis. The differential diagnosis of suspected de Quervain tenosynovitis is listed in Table 5.

DIAGNOSTIC TESTS

The diagnosis is clinical based on history and examination. In cases where osteoarthritis of the carpometacarpal joint is considered, pain relief with diagnostic lidocaine (Xylocaine) injection of the first extensor compartment excludes arthritic cause. Radiography, electromyography/nerve conduction studies, blood tests, and MRI or ultrasonography may be used to evaluate for alternative diagnoses.

DIAGNOSTIC STRATEGY

If the history and examination are consistent, no further diagnostic testing is needed. For suspicion of fracture or arthritis, radiography is an appropriate first step. If suspected, radial nerve abnormalities may be ruled out with electromyography or nerve conduction studies. If there is concern for infectious tenosynovitis, a complete blood count and measurement of inflammatory markers, such as erythrocyte sedimentation rate and C-reactive protein levels, are appropriate. If the patient does not respond to treatment or if the diagnosis is in question, an MRI or musculoskeletal ultrasonography may be ordered to further evaluate the first extensor compartment.

Data Sources: A PubMed search was completed in Clinical Queries using the key terms scaphoid fracture, ulnar neuropathy, and de Quervain’s. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were Essential Evidence Plus, the Cochrane database, the National Guideline Clearinghouse, and UpToDate. Search date: August 2011.

Also Read: Long Bone Fractures and Complications

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Lifestyle

21 Most Popular Patio Furniture To Get Before They Sell Out

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Popular Patio Furniture

In the summer, the right patio furniture makes a world of difference in your outdoor space. It’s the best way to maximize the pleasant weather without leaving the comforts of your home.

Whether you’re looking for a complete dining set for hosting guests, a chat set for cozy outdoor conversation, or some lounge chairs for your patio, the priority should always be high-quality construction designed for outdoor exposure and long-term use.

The available choices can be overwhelming for the first-time buyer, so it’s essential to narrow down first what it is you’re looking for, the outdoor space you’re planning to fill, and a target aesthetic, if you have one. These criteria will better steer you towards the right pieces for you. Keep in mind that outdoor furniture is in high demand these days, so it’s best to start your shopping early before the best picks get sold out.

To help your search, we have curated some of the most popular, tried-and-tested picks that are guaranteed to turn your patio from mediocre to stunning!
The Season’s Most Popular Patio Furniture

#1. Vincent 7 Piece Extendable Outdoor Patio Dining Set

This Vincent 7-piece set, crafted from weather-resistant acacia wood, comfortably seats six. It comes in three versatile colors一gray wash, brown, and dark brown一and features a chevron detailing that brings a fresh and modern touch to any outdoor space. The table can be extended for added comfort and accommodate an outdoor umbrella at its center.

In terms of upkeep, the occasional reapplication of teak oil will protect and maintain the set’s beautiful satin finish for years.

Those looking for a great patio set to gather around in any weather need to look no further! Whether you’re dining with friends, family, or new acquaintances, this outdoor set creates the perfect atmosphere for openness and conversation.

#2. Midland 6 Piece Outdoor Dining Set

Laid-back style and comfort come together in this Midland set. It’s an excellent pick and is a reliable outdoor dining set that isn’t too bulky or formal. This dining set is made from durable acacia hardwood and comes with a hideaway butterfly leaf table, four armchairs with soft and weather-resistant cushions, and a three-seater bench. This easy-to-assemble dining setup allows space for extra guests and offers more outdoor entertaining possibilities.

This Midland set provides the perfect scene for those who love enjoying breakfast under the gentle morning sun.

#3. Dark Brown 4 Piece Acacia Wood Conversation Set

When the space permits, having a conversation set in your outdoor space is a must!

The two features this conversation set is praised for are their classic elegance and sturdiness. This four-piece set, which includes a chic coffee table, a loveseat, and two patio chairs, lends itself to hours of good conversation in total comfort. Its understated look makes it easy to style in any space and brings a touch of tropical luxury to the home. Make this the perfect outdoor spot for celebratory toasts or afternoon catch-ups with old friends. Also, stylish and functional outdoor lighting can make this a cozy corner for drinks under the stars!

#4. Terrace Natural Finish 3-Piece Outdoor Bistro Set

Elevate your porch or balcony with this 3-piece bistro set. This set comes in synthetic rattan and a powder-coated aluminum frame, built with both comfort and long-term durability in mind. The glass-topped side table and cushioned chairs allow for relaxed outdoor snacking or drinking with a friend.

The quality of the materials, which can withstand constant exposure to the elements, and the set’s classic look make this a favorite of those looking for timeless furniture. You can also stock up on extra outdoor seat cushions in different colors or patterns so you can easily switch up the set’s look depending on your mood, the season, or even an event!

#5. Extendable 3 Piece Outdoor Patio Dining Set

Outdoor dining at home is made glamorous with this picnic-style 3-piece dining set. Its extendable table and two benches, which feature a stylish chevron design, allow for spacious but cozy seating and can suit a deck, backyard, or patio well. Thanks to its rich color and satin finish, the set’s sleek yet natural look allows for a modern or boho styling. You can also attach an outdoor umbrella at the center for a bit of shade on sunnier days.

As with other acacia furniture, this set only requires the occasional reapplication of teak oil to maintain wood vibrance.

#6. Modern Grey Faux Rattan Set Of 4 Outdoor Sectional

Homeowners who love hosting family get-togethers or mini backyard events will find this outdoor sectional a must-have. This faux rattan 4-piece set with lush, cushioned seats provides spacious and comfortable seating for guests, but it can also serve as a relaxing space for napping or reading. This well-sized set can serve as the anchor in your patio where everyone gathers around, and it can also work for a cozy corner in your backyard.

You can consider matching the sectional with this glass-topped faux rattan coffee table as an added option. The glass top adds a subtle touch of luxury and provides more surface area which you can decorate as well.

You can further personalize the sectional by adding some tasteful outdoor pillows for additional style and comfort.

#7. Lutterworth Set of 3 Outdoor Bar

Level up your entertaining capacities with a stylish outdoor bar set. This minimalist 3-piece set, made with a sturdy metal frame and solid acacia wood, can be your guests’ next favorite nook at your place. It’s a perfect spot to enjoy drinks outside when the weather’s great, host a game night with friends, or even have a quick afternoon snack session under the warm sunlight.

For design coherence, you can match it to a dining set with a similar, natural finish, like this Grayton Outdoor Dining Table. Finish the space with some decorative lights to bring function and ambiance for evening use.

#8. Crosswinds 7 Piece Outdoor Dining Set

Another spacious option is this 7-piece outdoor dining set. With its sturdy acacia wood construction, soft cushions, and x-back design, this dining set brings a rejuvenating coastal vibe to your outdoor space. The dining table comes in a butterfly leaf design that allows for extension and thus additional space for more guests, as well as a slot for an outdoor umbrella at the table’s center. This set works wonderfully on a patio, deck, or poolside.

The material is reliable and weather-resistant and takes only an occasional reapplication of teak oil to ensure the set’s best quality for many years.

#9. Quartz Natural Table And Chair Set

This natural dining set comes highly recommended for those with space-saving considerations. It comes with a lightweight but sturdy, foldable table and set of four chairs designed in an elegant, contemporary fashion. Whether you keep it as permanent patio furniture or only use it as an additional dining setup for gatherings, this set brings functionality and a beachy vibe to any outdoor space.

To enhance the set’s natural look, consider placing it on an outdoor rug for an interesting visual effect.

#10. Canaan All-Weather Wicker Outdoor Deep-Seat Dining Sectional Set with Sofa, Loveseat, 26 “H Cocktail Table, and Two Stools

Deck out your large patio with this complete sectional all-weather wicker set. The set is built on a sturdy, rust-proof aluminum frame and comes with a sofa, loveseat, a glass-covered cocktail table, and two stools that allow for spacious entertaining. This set’s design includes weather-resistant cushions to withstand different weather conditions, so you can rest at ease knowing your outdoor sofa will be perfectly fine come rain or shine. The set’s resilient structure and modern style make it a crowd favorite.

Whether you’re planning to host intimate family get-togethers or game nights with friends, this set serves as a perfect gathering spot. For added glamour, you can install yard lights around the area.

#11. Akita Dining Set In Black

For fans of faux rattan, this Parson-style dining set combines the best of outdoor dining with the style of bar sets. It comes with a sleek, glass-topped table and six cushioned stools.

Reminiscent of those poolside bars in tropical getaways, this easy-to-clean set brings a laid-back touch to any outdoor space. A nearby fire pit can allow you to dine comfortably on this set even when the temperature drops. For added convenience, you can also purchase a bar cart on which you can display or place your refreshments.

#12. Athens All-Weather Wicker Outdoor Conversation Set with Coffee Table, Set of Two Chairs, and Two-Seat Bench

This all-weather wicker conversation set embodies everyday luxury. This four-seater set, made with high-quality dark brown wicker, sturdy wooden legs, and soft cushions, immediately channels the laid-back vibe of a beachside paradise. It’s a great spot for gathering your closest friends or reading your next favorite book during a bright and cool morning.

Complete the area with a tastefully chosen rug and some décor一like plants or sculptures一to give the space more warmth and fun. Such a corner is sure to gather some compliments from your guests.

#13. Andover All Weather Outdoor Bistro Set with 4 Rope Chairs and Bistro Table

The furniture in one’s house can say a lot about the owner, and this all-weather bistro set screams class and confidence. The chairs are constructed from a solid but lightweight aluminum frame wrapped with textured polypropylene rope to give a natural but modern look.

They also come with weather-resistant cushions, but best to keep them in a covered area as much as possible. Store them well when not in use, as that can significantly extend the cushions’ lifespan.

This Andover set is guaranteed to check your boxes for those looking for a classy bistro set to elevate their patio, deck, or backyard.

#14. Contemporary Dark Brown Acacia and Navy Blue Modular Patio Set

Being able to entertain guests at home can be one of life’s best pleasures. To do so, equip yourself with a welcoming space decorated with comfortable but stylish furniture. This contemporary modular patio set is an excellent pick for comfort, style, and versatility in one furniture set.

This modular set in durable brown acacia wood takes inspiration from the coastal aesthetic with its slat side design and firm cushioned seats. What’s great about this set is you can quickly move around the pieces一left and right armchairs, three armless chairs, and an ottoman一and cushions to achieve a certain look appropriate to your event. Whether you’re hosting a fun family barbecue, your neighborhood book club meeting, or a lavish anniversary party at home, this elegant patio set puts the “fun” in “function”!

#15. Simple Weave Complete White Sectional With Table 4 Piece Outdoor Set

Don’t be deceived by its name; this outdoor set may be “simple,” but only because it does a great job at understated elegance. This sectional, designed to withstand the elements, channels a coastal-casual vibe with its weave pattern and geometric yet airy look. Spacious and comfortable, this set has a sturdy galvanized steel frame, waterproof resin wicker, and water and UV-resistant deep blue cushions.

The glass-topped cocktail table brings a modern finish that can be accented well with a quaint vase or stack of reading materials, should your outdoor area be covered. Overall, this set is a favorite among those who love to entertain or have expansive outdoor areas that need something like this to give it depth and comfort. You’ll find that this set can provide a great spot for conversations over morning coffee or a card game with your closest friends.

#16. Dolavon Convertible Lounge Settee

There is an undeniable charm in convertible furniture. This Dolavon lounge settee is one such piece that you can magically transform from a loveseat to a chaise lounge at will! To do so, you need to extend the base of this furniture to create additional seating or space for you to lounge more leisurely. This settee is a great choice for those working with a small space, as it can easily switch back to its two-seat mode.

Some have placed this versatile piece by the poolside to allow for comfortable sunbathing for those who wish it, while others love the elegant look it brings to their patio.

Like others on this list, this settee can withstand exposure to outdoor elements. Its solid acacia frame, which is mold resistant, provides strong support, and the upholstery is guaranteed outdoor-safe so you can unwind without worry.

#17. Caspian Eucalyptus Wood Outdoor Lounge Chair with Mesh Seating

Not all lounge chairs are created equal–and this Caspian eucalyptus lounge chair is a deserving crowd favorite. Durable eucalyptus wood and poly woven seating make this piece; no wonder it’s one of the market’s most versatile and reliable lounge chairs. Not only does it provide superior comfort for all-day lounging, but this piece can also be styled easily with virtually any aesthetic due to its simple yet elegant design. It comes with a black mesh seat on a frame with a natural finish for a contemporary look.

This lounge chair works great for poolside use due to its water-resistant build, but you can place it on the patio or backyard for added comfort in those spaces.

#18. Arna White Bench

Bring a piece of Parisian romance into your home with the Arna bench. Its sturdy metal build, finished with a charming antique white coating, is an unmistakably classic look that will bring character to any space. You can add this to a corner in your garden or patio. The bench’s white finish also lends itself to various design possibilities, like having a blank canvas on which you can exercise your creativity. Some great ways that others have enhanced this piece are by surrounding it with plants or placing it by the poolside to create a stunning visual contrast.

Add some yard lights by the bench to create a cozy spot perfect for stargazing or intimate evening conversations.

#19. Gray Princeton 2-Piece Hanging Basket Floating Chair with Stand

Break the monotony of your outdoor space by investing in something unique like this gray Princeton floating chair. This hanging seat will undoubtedly bring comfort if you hang it from a porch, tree, or stand. You can melt into its soft, weather-resistant cushions as you read a book or enjoy an afternoon cup of tea during a pleasant day. The gentle swinging of the chair makes it a cozy spot for outdoor naps, too!

The best part is that this piece has a sturdy aluminum frame and a mixed synthetic weave that beautifully emulates natural materials with much higher durability. Because of this craftsmanship, you won’t have to worry about maintenance aside from the occasional dusting to keep this piece in its best condition.

#20. Vernon Grey Bar Table

A bar table, like this Vernon Grey Bar Table, is a must-have for those who love entertaining guests at home, especially for gatherings with a warm, tropical vibe. Its material is eco-friendly acacia wood in a charming white-washed finish. It also features a contemporary slatted design and can serve as the center of attention in any home event. Whether it simply holds some décor, cocktail platters, or an array of drinks, this bar table is sure to bring both function and style to your outdoor space.

Alternatively, this table also comes in a natural, teak brown finish that better complements warm tones.

#21. Grey Resin Modern Outdoor Accent Table

Last on our list is a statement piece that will capture any guest’s gaze. This grey outdoor accent table, made from a lightweight but long-lasting poly cement designed to withstand any weather, has charmed many art enthusiasts and interior designers because of its organic form that brings a touch of creativity into any space. The tabletop has a matte finish for that contemporary vibe, while its acacia legs have a subtle polish.

Compact, sturdy, and unique, this accent table can stand out anywhere you place it. Try matching it with more natural elements like wicker seats or floral décor to bring out its full potential.

What To Consider When Picking Out Patio Furniture

Any popular items above would be a solid pick for your outdoor space, but finding the perfect one depends on your exact situation. After all, furnishing the patio is no easy feat. You would have to balance aesthetics, function, and durability to give your home the comfortable outdoor space you and your family deserve.

Your Home’s Location

For starters, depending on the climate where you live, some furniture options are better than others. All the outdoor furniture in this list can withstand exposure to outdoor elements. However, it’s still best practice to choose materials that are more likely to last longer in your kind of weather, so doing some research or consultation beforehand can narrow your choices wisely.

For example, outdoor wood furniture may be susceptible to cracking and splintering if you live in a hot and dry location. In contrast, your furniture might be vulnerable to rot in places with high humidity. Meanwhile, if you live in an area with frequent rains, resin wicker, treated wood, and coated metal are wise picks.

You would also likely want to stay away from iron if you live by the coast, as the salty air can negatively interact with the metal. In such places, aluminum and wicker are fantastic choices.

Ultimately, while all outdoor furniture on this list can last as long as possible, wear and tear are inevitable, so you must consider where and how you plan to use your furniture to anticipate how long it will last.

The Size Of Your Outdoor Space

Another factor for consideration is the size of your space. You may like that modular sectional set, but if your patio isn’t large enough, furniture like that can make the space feel small, uncomfortable, and restrictive. For such areas, a well-chosen chat set or bistro set may suffice.

The contrary is just as bad. Placing small furniture sets on an expansive patio or porch will make your outdoor space feel unwelcoming, cold, and empty. In this case, a sectional or a large dining set would likely give the space the anchor it needs. Finish off the look with well-placed décor.

When going outdoor furniture shopping, ensure the measurements of your patio or space. Having a clear objective based on the size of the space you plan to fill will save you lots of precious shopping time!

Comfort And Function

The best outdoor spaces are both functional and well-designed. Having attractive but uncomfortable furniture defeats the purpose of creating that space where you can relax outdoors from the comfort of your home. At the same time, choosing purely functional pieces that bring no aesthetic value to your space would be a waste.

In furnishing your outdoor space, whether it’s a patio, deck, or balcony, make sure to consider the experience of using your chosen pieces. Do you see yourself or your family using that dining set or sofa? If you entertain guests often, do you see them gravitating towards those sets and pieces? How well does it blend in with the look of your home?

The Demand For Outdoor Furniture

As a last consideration, it’s important to remember that high-quality and stylish outdoor furniture is in high demand. Some make the mistake of thinking there’s an endless supply and resorting to sub-par picks that either show signs of breakage a year in or lack tasteful design due to a short shopping timeline. So if you have an outdoor space needing furnishing, it’s highly recommended that you research first, so rest assured that the pieces you’re bringing into your home can support you and your family’s moments for years to come. Don’t rush the search; your future self will thank you later as you sit on the durable and chic outdoor bench you picked. At the same time, when you find something that strikes you, don’t hesitate too much–sometimes you have to go with your gut, or someone else will!

We know how stressful it can be to shop for outdoor furniture, but it can be a delightful process with the correct information. After further reflection on your needs, revisit the top furniture picks in the list above to see if any of them is right for you! The best part is, when you find one you’re in love with, you can easily place an order online and wait for your dream furniture to arrive at your doorstep. Easy as that!

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#1 Rated Dentist in Deltona, Florida | Deltona Smiles

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Dentist In Deltona

If you live in the Deltona area, the name Deltona Smiles probably isn’t that uncommon to you. It’s because Dr. Zerivitz and his fabulous staff have been gracing the city for a whopping 40 years now. Rated the #1 dentist in Deltona, Deltona Smiles truly puts a smile on their patients. 

Dr. Zerivitz started as a US Navy Dentist, stationed in Baltimore, Maryland. Once his military service was fulfilled, he immediately moved to Deltona, Florida to continue his passion for all things dental. He started Deltona Smiles and has never looked back. Also grounded in the community, he serves as a volunteer outreach dentist, traveling to Brazil and Thailand.

He is a recipient of The Greater Orlando Business Ethics Award, which his patients know, reflects his sense of family and his giving back to the community. He prides himself on his experience and education in the dental industry as it’s ever-evolving.

His practice offers the typical routine services to maintain good dental wellness along with cosmetic dentistry and the prevention of many oral afflictions, many of us suffer from. He also treats gum disease, TMJ, extractions, crowns, dentures and the list goes on from there.

Always a friendly and professional environment, he and his staff at Deltona Smiles are continuously highly reviewed and rated by their loyal patients. New patients and children are always welcome to make Deltona Smiles their one-stop dental practice. 

In the near future, Dr. Zerivitz’s practice will be adding Saturday hours for more convenient scheduling for their patients.

To request a consultation, contact them today at (386) 574-5201 or visit their website at www.deltonasmiles.com 

Top 6: Best Dentists In Deltona

Also See: #1 Rated SEO Company

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The Best Pool Accessories for 2019

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pool accessories

Making the most out of your summer might as well be a full-time job. At the very least, you’ll need the right toys for your pool, even if that means upping your game to keep up with the Jones’. Lucky for you, you don’t have to spend as much as you think on the latest and greatest pool accessories. 

Technology has come full circle and made its way into your backyard paradise. Check out a few new items on the market to make your staycation a little more enjoyable and that guilty pleasure you need.

Also read: Pool Water Maintenance Mistakes

Four Great Pool Accessories

Everyone loves music while they are poolside. Now you can opt to drown out your neighbors with a set of ever-so-cool floating, wireless and waterproof speakers. And yes, we said waterproof. These bring the noise, with most offering subwoofers for perfect pitch.

For those brisk, chillier nights, consider a towel warmer for you and your guests. Don’t just limit these to inside the home anymore. The takeaway here is that your body will thank you with a warm hug, and your guests will have something to talk about, later on.

Now, possibly the best of the best pool accessories to have in 2019 is the ever-impressive giant inflatable movie screen. Impress all your friends by chilling out with a movie in the pool as you float and watch the latest and greatest summer flick, you may just want to hold off on a screening of Sharknado. 

And this might not be the coolest, hip accessory of the season although our amphibian friends would think so, the critter escape ramp. This is easily placed anywhere in the pool and it allows squirrels, frogs, rabbits to easily save themselves. But buyer beware: you’re on your own when it comes to those Florida alligators.

Bring Out The Best In Your Pool

You’ll be the talk of the neighborhood, even if you don’t like all the neighbors. You’ll have a smile on your face and a few dollars left in your pocket with these pool accessories. In the market for your own backyard pool? Let Artesian Pools take care of all your custom pool needs, today.

Also See: #1 Rated SEO Company

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Pool Water Maintenance Mistakes

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Pool Water

Owning a swimming pool is a lot of fun things, but it’s also a commitment. There’s cleaning that needs to be done, consistently and regular maintenance that also needs to feature.

And the biggest pressure of all? Knowing you could be messing something up without even realizing it. After all, a swimming pool is a delicate balance of chemicals, cleaners, and bacteria. Throw any of those things out of whack, and the whole system becomes compromised.

Join us today for a closer look at three of the most common pool maintenance mistakes most pool owners make.

Shocking Pool Water Directly

Treating your pool water with chemicals is more commonly known as “shocking” it, and typically involves flushing it with concentrated chlorine. As you may know, chlorine bleaches things and that applies to everything that goes into your treated pool water, as well. If your concentrations are off, it can ruin your clothes, turning them from black to pink and white to yellow.

Also read: Five Pool Safety Tips

Of course, how concentrated your chlorine is is completely within your control, and you actually can’t over shock your pool. Directly shocking your pool water can compromise the integrity of your pool liner, as well, bleaching it to the point where it becomes extremely brittle. 

Dissolve whatever chemicals you’re shocking your pool with in a bucket before adding them to your pool water. This distributes the shock more evenly, protecting your liner and producing a more even shock. 

Forgetting To Brush

We all know brushing is important, but when was the last time you brushed your swimming pool? Regular vacuuming is a standard when it comes to cleaning your pool, preventing gunk and debris from accumulating and spoiling your swimming experience. Brushing adds to this cleaning process, lifting dirt and mossy build-up.

The process is simple. Simply scrub at any accessible areas with the pool brush until they’re clean. Remember to get into the tighter areas you may not think of at first:

  • Behind and around the ladder
  • On and around the stairs
  • Up to the water-line
  • Any and all corners and crevices

A simple brush, once a week or more often, is all you’ll need for a healthier, cleaner swimming pool experience.

Automatic Pull Cleaners For An Algae Problem

Pool algae is a big enough problem, even if you’re doing a good job at it. You may be tempted to invest in an automatic pool cleaning unit in order to save yourself some time and trouble. You’re going to want to resist this urge, however, as these pressure-based cleaners don’t typically clean very well.

Automatic pool cleaners use pressure to push pool debris around the circumference of your pool and back through a mesh bag for collection, later on. This might sound ingenious, but more often than not it just means your algae is traveling around your pool, depositing at different points and not cleaning much of anything at all.

This is a pool management issue that’s actually pretty straightforward to solve. Get a manual pool vacuum and switch the filter to before removing the drain plug. This will lead to a nominal amount of water loss but the algae will leave along with it. 

Also See: #1 Rated SEO Company

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Introducing: The Desert Rose Kitchen Installation

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desert rose

A kitchen installation is about more than just slapping a new coat of paint or a few cupboards on the room itself. It’s about reinventing your home. Bringing out something special with a few well-thought-out items and accessories. It’s about taking a space you already know and making more out of it.

Today’s kitchen installation hits that balance of decor and comfort just right. So, without any further ado, we’d like to introduce you to the Desert Rose, from Cabinetry Creations, Inc.

Also Read: Just A Pop Of Red: A Daring Kitchen Installation

Warm and Comfortable

One of the best parts of being at home is feeling like you’re at home. And, while a gorgeous, expensive home installation full of new devices and furniture is great, the truth is nothing beats a warm, inviting home space. 

Desert Rose is exactly that home installation. Featuring warm, comfortable wood cabinetry flanking an offwhite kitchen island and wicker-backed furniture, this is a place for making happy memories. Whether you’re cooking dinner for the family or enjoying a good book while the kids are away for the weekend, the dark wood shelving and muted walls of this installation give it that classic home feeling.

Bright and New

Of course, a brand new kitchen installation should look at new, and Desert Rose has new looks to spare. Modern and spacious, you’ll be able to take in all corners of your open-plan home, from the gleaming island sink to the recessed lighting, dishwasher flush with cabinets and gas stovetop.

An Open Living Space

This kitchen installation is ideal for smaller living areas, owing to its open plan design. Installing a kitchen island and opening up your kitchen area is a great way to use limited space. It also looks great, creating a more welcoming and open living space. 

Get the family over for dinner and enjoy a great evening in the “Desert Rose Kitchen”, designed and installed by Cabinetry Creations Inc.

Desert Rose

For a home to be both comfortable and attractive, you need to know how to balance colors with comfort elements. With its warm colors and elegant simplicity, the Desert Rose embodies that balance perfectly.

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Dogs For Elderly People: Three Top Breeds

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dogs for elderly

Dogs are one of mankind’s most beloved companions, spanning cultures, genders, income brackets, and, especially, ages. Elderly people derive a lot of love and affection from their pets, keeping them company and preventing loneliness. Dogs help their owners stay healthy, keep a schedule, and find the motivation to go about their daily lives. Studies have shown they help to improve moods, reduce stress, and aid in their owners’ overall cognitive ability.

But what factors should you consider when buying dogs for elderly loved ones in your life? Join us today as we unpack several of the best breeds out there, and learn why they’re the perfect fit.

Also Read: Elderly Fall Alarms: The Threat Of Taking A Fall As An Elderly Person

What To Look For

Finding the right dog to match an elderly lifestyle is a balancing act. You want a dog that is small enough to not worry about it injuring the owner, but large enough that they won’t trip over it.

An overly powerful dog could easily pull or push their owners over if they get excited and that can lead to serious injuries. Avoid pets that were bred to do work, guard or fight because their size and strength will not be appropriate.

Lastly, be sure to look for a breed with fewer known health problems. Specific dog breeds have more common health issues than others, so avoid breeds with hip dysplasia or early blindness for best results.

Poodle

Poodles are the classic “elderly” pet, owing in no small part to their small size and “permed” hairstyles. Available in small, medium and large sizes, this is a dog for all occasions, with their calm and loyal sensibilities. Unquestionably smart and trainable, they also score points for being completely hypoallergenic.

Pug

The pug may be one of the goofier pets on the market, but they are also a wonderful pet for the elderly. This dog enjoys being around people and does not require a lot of exercise, which is a bonus for somebody with a hip problem.

They are also extremely affectionate, making them an ideal companion. Add to that their small size, ideal for apartments, and you’ve got an adorable pet with a winning personality, perfect for grandma.

French Bulldog

One of the easiest companions anywhere in the dog world, the French Bulldog brings a playful and obedient element to any home. You’ll enjoy a mostly-quiet experience, with easy obedience and very little need for trimming and maintenance.

Dogs For Elderly: Now You Know

When it comes to choosing dogs for elderly companionship, it’s important to know what you’re looking for, and why. Find a dog that is physically the right size, as well as the right temperament and volume, for improved elderly health. Remember to take your time during your search and find an animal that really speaks to you.

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Stages of Grief: Can We Really Know That Much?

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stages of grief

Elizabeth Cooler Ross’s “five steps of grieving” framework has been the go-to method recommended to grieving families and loved ones for many years. It’s a famous breakdown of the process, dividing into five individual stages. These steps proceed in the same order almost every time, after which the person in question can achieve resolution on their grief. 

But is it accurate? Are the five stages of grief a myth or a convenient story we tell ourselves to help make dealing with the passing of a loved one easier. Join us today as we break down the 5 steps of grieving, their efficacy, and how the process holds up in the light of day.

Also read: Introducing: The Death Positive Movement

What Are The Five Stages?

The traditional five stages of grief include:

  1. denial 
  2. anger 
  3. bargaining 
  4. depression 
  5. acceptance 

It’s safe to say these stages are applied across the board when people are obviously processing grief. These are a standard by which most of us navigate these turbulent waters, but what’s interesting is that newly published studies have indicated this might not be true. 

New research describes the sadness of mourning as more of a stress response than something we can plot out and create standard rules for. Every person is unique, and no two people experience sorrow in the same way. So, with that said, how could we claim that everyone would have the same standard set of recovery steps as each other? 

Taking it a step further, there are claims that actually sticking to these five steps can have the opposite effect, robbing you of your peace because you’re not reaching each step “on time”. Or even in order. Because it’s completely possible to experience a different order of emotions or even none of these emotions and be completely normal.

Final Thoughts

Sadness is a 100% natural experience following the loss of family or a loved one. You don’t need to worry about processing it “properly”, so long as you are being good to yourself during the process. Reach out, ask for counseling or support, and lean on the people around you if you need. And, if you need assistance with an upcoming funeral, visit Woodward Cremation and Funeral Services.

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Winter Pool Equipment Check List

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Pool Equipment

With fall approaching and fewer reasons to get in the pool, this is the perfect time to check your pool equipment ahead of next Summer. Because the truth is, we all have the best intentions but most summers we’re too busy enjoying the pool to keep up with maintenance.

So join us, today, for a super quick roundup of what pool equipment to check and why, and get ready for a great summer.

Also read: Pool Water Maintenance Mistakes

Pool Water Maintenance Mistakes

Pool Equipment: Check and Check

The whole point of a swimming pool is being able to enjoy it when and where you want to. This goes out the window, however, when Summer finally arrives and your pool isn’t working the way it should.

Your pool and equipment are the twin pillars of a safe, clean, fun-filled summer swimming experience. During the upcoming “off-season”, make sure to keep the following checks under wraps:

  • Holes In Skimmers: Once the structural integrity of your pool skimmer goes out, you can’t rely on it to work 100% properly anymore.
  • Compromised Leaf Rakes: Sun and weather damage over time can make a rake less effective, so it’s best to check on these while you have the time.
  • Pool Vacuum Bags: Check to confirm that you have enough bags and that the bags you have aren’t degraded.
  • Cracks and Damage: Weathering on the plastic components of your brushes, handles, and vacuum hoses compromises their efficacy, so replace or repair these as soon as possible.
  • Clean, Functional Equipment

A swimming pool is a system with many parts, all of which need to be in working order for the system to work properly. When a cleaner, filter, or other component fails, it can let the entire system down. This is why it’s important to repair, replace, and maintain any tools and parts in order to avoid issues in the coming Spring and Summer months.

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Just A Pop Of Red: A Daring Kitchen Installation

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Sometimes, you’ve just got to give your home something a little…daring. It’s one thing to create a comfortable, quiet and unintimidating room. It’s another thing entirely to say something with your kitchen. And when it comes to kitchens that say things, nothing says it louder than Just A Spot Of Red.

Cabinetry Creations Inc.’s bold, vibrant kitchen installation is equal parts crisp white surfaces and elegant wood cabinets. From the recessed lighting to the electrifying red central hanging lamp, this is a captivating installation. Let’s take a closer look.

Also read: Home Designs Sydney – Kitchen Trends For 2018

Geometry

Creating a beautiful room installation is subtle work. It takes a balance of functionality with the countertops, cupboards and lighting, with boldness in the colors and decor. 

With Just A Pop Of Red, Cabinetry Creations Inc. uses a balance of square and rectangular countertops, cupboards and wall panels with rounded bowls, lights, and vases. The entire space is finished off with a bright red lamp like a literal cherry on top, offsetting the room for a charming finish.

Contrast

Sleek frameless cabinetry and a recessed oven keep the wall line unbroken and smooth, with wooden slats adding a rich, textured frame around everything. This kind of contrast is incredibly important to creating an authentic, gorgeous living space.

Imagine a kitchen decked out entirely in white. It might sound nice, but even in just the wrong light, it can seem sterile and uninviting. Similarly, a space covered in wood and darker decor can feel “heavy”. Contrasts like A Splash Of Red give the eye more to look at, and the kitchen installation results? Well, just take a look.

Open Plan Design

Open plan spaces aren’t anything new in the world of kitchen design, but Just A Pop Of Red makes fantastic use of this style. Elegant and understated, this kitchen opens up to the house around it, making it seem twice as big as a result.

The effect is also to create a “warmer” space. Have guests over for dinner or the kids watching TV in the nearby living room, and everyone in the room can talk to each other. Everyone can smell what’s cooking, without going back and forth between rooms, for a wide-open home space custom made for building happy memories.

A Pop Of Red is a kitchen installation that brings living spaces to life, with bold contrasts and innovative space usage. See more of this installation or find out more about their services, today.

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Can New Windows Increase The Value of Your Home

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value of your home

Increasing the value of your home is something you can accomplish in various ways. Sometimes, homeowners choose to upgrade their kitchens or convert their bathrooms. They may hire a topiary designer, slap on a new coat of paint, or finish their basement.

Alternatively, replacing or adding windows may help add to bring out the best in your home. Join us today as we put home window installations under the microscope, and let’s boost that home value with a high-end window.

Also read: Home Grants For First Time Buyers: More Options Than You Think

Does Adding Windows Add Home Value?

Installing windows in your home is, hands down, one of the most straightforward ways to increase its value. Realtors have recorded cases where, for instance, investing $ 10,000 in simple vinyl replacement windows for homes raised a home’s price to $ 8,000. This represents 80% of your return on investment.

Adding a new window to your home makes your home more valuable for a variety of reasons. Curb appeal improves almost as soon as your new windows are installed. When passersby pulll up in front of your house, and old, ugly windows greet them, what do they see?

Replacing your windows as soon as possible is a great way to enhance your home’s visibility, making it look more modern, well kept, and valuable. And as your curb appeal swells, the value of your house will increase exponentially.

A Note On Energy-Efficiency

Worried you’re spending too much money every month running heating and cooling systems? Don’t worry, you’re not alone. Many homeowners face this same problem, every year, with hundreds of dollars and their HVAC systems on the line.

Adding new vinyl windows to your home has been shown to help. These replacement windows make your home more energy efficient, helping to avoid wasted energy and skyrocketing bills. And the concept’s simple enough:

This is another great way to increase the market value of your home. 

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