He also describes that he has numbness in his feet.  When I asked him to describe this in more detail, the numbness is actually restricted to his toes.  Left is slightly more affected than the right.  He denies any tingling or paresthesias.  He also described that he is slowly losing control of his hands.  He thinks that he is dropping objects due to weakness or incoordination in his hands.  This has also been occurring for the past one to two years.  He has noticed that buttoning his clothes is more difficult for him.  He also does not have any numbness or tingling in the hands.  He does have a history of chronic low back pain.