United States Court of Appeals For the First Circuit

No. 20-2051

CHE BLAKE SOSA, Plaintiff, Appellant,

v.

MASSACHUSETS DEPARTMENT OF CORRECTION; MICHAEL L. RODRIGUES, former Superintendent, MCI Cedar Junction, in his official and individual capacities; CAROL HIGGINS O'BRIEN, Commissioner of the Department of Corrections, in her official and individual capacities; STEPHEN KENNEDY, former Deputy Superintendent of Operations, MCI-Cedar Junction, in his official and individual capacities; VANESSA RATTIGAN, MPCH Health Services Administration for MCI-Cedar Junction, in her official and individual capacities; AYSHA HAMEED, MPCH on-site Medical Director for MCI-Cedar Junction, in her official and individual capacities; JENNIFER VIEIRA, former MPCH Nurse Practitioner for MCI-Cedar Junction, in her official and individual capacities; ANN EVANS, MPCH Licensed Nurse for MCI-Cedar Junction, in her official and individual capacities; JOANN LYNDS, former Deputy Superintendent of Reentry and Americans with Disabilities Act Coordinator at MCI-Cedar Junction in her official and individual capacities; JAMES M. O'GARA, JR., Department of Correction ADA Coordinator for Inmates, in his official and individual capacities,

Defendants, Appellees,

JAMES SABA, former Superintendent, MCI Cedar Junction, in his official and individual capacities; et al.,

Defendants.

APPEAL FROM THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MASSACHUSETTS

[Hon. Nathaniel M. Gorton, U.S. District Judge] Before

Barron, Chief Judge, Lipez and Howard, Circuit Judges.

Jeffrey P. Wiesner, with whom Jennifer McKinnon and Wiesner McKinnon LLP were on brief, for appellant.

Margaret Melville, Senior Litigation Counsel, Massachusetts Department of Correction, with whom Nancy Ankers White, Special Assistant Attorney General, Massachusetts Attorney General's Office, was on brief, for appellees.

August 14, 2023 LIPEZ, Circuit Judge. Che Blake Sosa, an inmate in the

custody of the Massachusetts Department of Correction ("DOC") who

suffers from severe arthritis in his shoulder joints, appeals from

a denial of preliminary injunctive relief. Initially, when

restraining Sosa, the DOC used "rear cuffing" -- handcuffing with

his hands positioned behind him -- with a single standard handcuff.

Then he was rear cuffed using two standard handcuffs linked

together, or "double cuffs." Still later, custom handcuffs

modified to have the span of double cuffs were used. Before the

district court, Sosa challenged these restraint procedures,

arguing that because of the unnecessary pain they caused in his

arthritic shoulders, the use of such restraints violated his rights

under the Eighth Amendment and Title II of the Americans with

Disabilities Act of 1990 ("ADA").

As preliminary relief for the pain caused by these

alleged violations, Sosa sought a court order requiring the DOC to

adopt the following procedure to restrain him when he is moved

within his correctional unit: initially rear cuffing him in his

cell, but with custom handcuffs that are at least three inches

longer than double cuffs; then transitioning him into waist chains

once he is taken out of his cell. Approving as reasonable the

DOC's procedure of rear cuffing Sosa with double cuffs-length

custom handcuffs, the district court denied Sosa's request for

preliminary relief. We affirm.

- 3 - I.

Sosa is an inmate at MCI-Cedar Junction, a DOC facility,

serving sentences for multiple counts of aggravated rape and

related offenses. Inmates at MCI-Cedar Junction found guilty of

serious misconduct while incarcerated may be administratively

sanctioned to serve time in the Departmental Disciplinary Unit

("DDU"). DDU inmates are the most dangerous inmates in the DOC's

custody; most have been sanctioned for causing serious physical

injuries to staff or other inmates, or for attempting to escape.

Sosa was held in the DDU from 2003 to 2020, having received

multiple DDU sanctions for infractions such as stabbing two prison

officers resulting in life-threatening injuries, punching and

biting officers, and assaulting prison staff with urine and feces.

Sosa has also been sanctioned for possession of homemade weapons,

attempting an escape, assaulting correctional officers and medical

staff on numerous occasions, and stabbing his attorney several

times with a homemade weapon while in court.

Because DDU inmates are particularly dangerous, the

standard restraint policy requires them to be rear cuffed with

single handcuffs whenever they leave their cells. This restraint

method restricts freedom of movement to the greatest extent

compared to other commonly used methods, thereby providing

enhanced security.

- 4 - Following an MRI scan in 2004 that showed severe

osteoarthritis of his right shoulder joint, Sosa underwent

therapeutic surgery on that shoulder. Between 2010 and 2017, Sosa

submitted numerous medical grievances to prison administrators and

medical personnel, seeking a variance from the standard method

used to restrain DDU inmates because of what he reported as

agonizing shoulder pain from rear cuffing with single handcuffs.

Sosa's medical grievances for relief from the standard DDU

restraint method were consistently denied on the grounds that no

medical personnel had indicated a need for Sosa to be restrained

using alternative procedures.

In addition to submitting medical grievances to prison

authorities, Sosa also submitted a request for a reasonable

disability accommodation to the ADA coordinator at MCI-Cedar

Junction in January 2017, seeking an alternative restraint

procedure. After this request was denied, he appealed to the DOC's

department-level ADA coordinator. The department-level ADA

coordinator upheld the denial of Sosa's request in April 2017,

noting his ability to perform all his activities of daily living

even with the standard restraint procedure, the lack of a medical

indication for alternative procedures, and the continuing threat

he posed to institutional security.

In October 2018, Sosa brought suit pro se under

for two alleged violations of federal law by the DOC and

- 5 - various DOC personnel. Sosa first alleged that, given the severe

pain he experienced in his arthritic shoulders from rear cuffing

with single handcuffs, the use of the standard DDU restraint method

on him was cruel and unusual punishment violative of the Eighth

Amendment. He further alleged that this restraint procedure

violated his rights under Title II of the ADA.

In February 2019, Sosa filed pro se a motion for a

preliminary injunction ("February 2019 motion") to require the DOC

and its personnel to change the procedure used to restrain him

when he is removed from his cell. Specifically, Sosa requested an

order for the defendants (1) to stop rear cuffing him with single

handcuffs, and (2) to use waist chains to restrain him when he is

taken out of his cell. In August 2019, the DOC filed an opposition.

Among the exhibits attached to the DOC's opposition was an

affidavit signed by Christopher Fallon, then the Deputy

Commissioner of Prisons in Massachusetts, detailing Sosa's

extensive history of violence and disciplinary infractions.

Following a hearing in September 2019 on Sosa's February

2019 motion, the district court appointed counsel to represent him

in the matter of the pending motion. The court also ordered the

- 6 - DOC to arrange for Sosa to be examined by an independent physician

to determine the condition of his shoulders.1

In compliance with this order, the DOC retained the

services of orthopedic specialist Dr. Michael Elman.2 After

reviewing the 2004 MRI scan and recent x-rays, as well as

performing a physical examination, Elman concluded that Sosa

"certainly has evidence of severe bilateral glenohumeral

arthritis,"3 which limited his range of motion and was "clearly

responsible for pain," particularly upon "internal rotation" of

the shoulders. Elman also remarked that it seemed "understandable"

that handcuffing behind the back would "stretch [Sosa's] shoulders

into positions of discomfort."

Sosa retained a different orthopedic specialist, Dr.

John Wixted, as an expert.4 Following a review of Sosa's medical

1 By an "independent" physician, the district court meant a physician that did not have a "position [of] responsibility" to the DOC or DOC personnel. 2 Elman had a solo practice specializing in general orthopedics and arthroscopic surgery. He was not employed by the DOC. 3Glenohumeral arthritis refers to arthritis of the shoulder joint. See Stedman's Medical Dictionary 811 (28th ed. 2006). 4 It is not clear from the record on what basis Dr. Wixted was retained as an expert or how he was paid. Indeed, prior to the February 7, 2020 motion hearing, the district court ruled that it would only consider the report of "the physician who conducted the independent medical examination of the plaintiff," referring to Dr. Elman. Nevertheless, the court subsequently decided to consider Wixted's report.

- 7 - records and a physical examination, Wixted concurred with Elman's

diagnosis that Sosa has "severe end stage arthritis in bilateral

glenohumeral joints." As a result, Sosa's shoulders had "very

limited internal rotation," which was "worse on the right

[shoulder] than the left." Specifically, Wixted determined that

Sosa's right shoulder only had fifty degrees of passive internal

rotation, while his left shoulder had eighty degrees of passive

internal rotation.

He explained further that because "[p]lacing one's hands

behind the back" without discomfort requires at least 100 degrees

of internal shoulder rotation, restraining Sosa's hands behind his

back would force his arthritic shoulder joint beyond their limited

range of motion, causing pain. As an alternative to using rear

restraints, Wixted proposed restraining Sosa's hands at his sides,

which would avoid any shoulder rotation and hence be significantly

less painful.

After both medical experts had filed their reports, the

district court held a second hearing on Sosa's February 2019 motion

on February 7, 2020. At this hearing, the DOC explained the

procedure it had voluntarily begun to use in restraining Sosa upon

removal from his cell. First, Sosa would back up to the closed

cell door and put his hands through the "wicket" -- a slot -- in

the door. His hands would then be cuffed behind him using double

cuffs. With Sosa thus secured, the cell door would be opened and

- 8 - two prison officers would enter the cell, proceeding to transition

him into waist chains.

At the same hearing, the DOC also proposed to have a set

of custom handcuffs manufactured that would have a specially

elongated chain. It planned to rear cuff Sosa with these custom

handcuffs to initially secure him while in his cell, before

transitioning him into waist chains upon being taken out of his

cell. While the district court gave this proposal its approval,

it also ordered the DOC to first consult with Dr. Elman to

determine the appropriate length for the chain of the custom

handcuffs.

On March 6, 2020, Sosa filed a Motion to Order the

Department of Correction to Cease Using Painful Rear Restraints

("March 2020 motion"), which the DOC opposed. In this March 2020

motion, Sosa asserted that since the February 7 hearing, the DOC

had shifted from its previous practice of transitioning him into

waist chains when he is brought out of his cell to a new procedure

where he was kept in rear cuffs -- albeit using double cuffs rather

than a single handcuff -- when outside of his cell. In response

to this alleged change in the DOC's restraint procedure, Sosa

requested an order requiring the DOC (1) to initially rear cuff

him in his cell with custom handcuffs modified to be at least three

inches longer than double cuffs, and (2) to transition him from

rear cuffs to waist chains upon removal from his cell. In support

- 9 - of his motion, Sosa attached a letter from Dr. Wixted taking the

view that for a modified rear restraint procedure to avoid pain to

Sosa's shoulders, the chain would have to be long enough to allow

his hands to "hang at his sides."

At a status conference held on March 10, 2020, the DOC

insisted that its policy had always been to only transition DDU

inmates into waist chains if they were being moved to a location

outside the unit; when inmates are moved within the DDU, only rear

cuffing is customarily used. A DOC official, Assistant Deputy

Commissioner Sean Medeiros, explained to the court that frequently

transitioning an inmate between rear cuffing and waist chains

presented a "safety issue" because, during the moments when the

inmate is uncuffed, "the officers become vulnerable."

The DOC also notified the district court that because it

had not yet been able to consult with Dr. Elman about its proposed

design for the custom handcuffs, it was continuing in the interim

to use double cuffs to rear cuff Sosa. Sosa himself indicated

that rear cuffing with double cuffs had been "a Godsend" that

"helped alleviate" his pain "a great deal."

On March 11, 2020, Sosa was transferred to the Behavioral

Management Unit ("BMU") at MCI-Cedar Junction on the referral of

his mental health clinician. The BMU is a housing unit designed

to provide clinically appropriate DDU inmates with programming and

treatment with the aim of achieving sufficient behavioral

- 10 - stability to allow a safe return to the general prison population.

Nevertheless, because the BMU caters to inmates who have a record

of perpetrating serious physical assaults, rear cuffing is used

routinely to restrain BMU inmates when they leave their cells.

In line with this standard restraint policy, Sosa was

secured by rear cuffing -- albeit with the modification of using

double cuffs -- whenever he was moved from his cell to facilities

within the BMU. Because of the short distances between Sosa's

cell and the facilities within the BMU, such as the shower, the

medical triage room, and the therapeutic module, he would only

remain in rear restraints for short time periods of up to four

minutes at most.5 However, he frequently experienced rear cuffing

because he was moved between his cell and facilities within the

BMU multiple times a week.6 When traveling to a location outside

the BMU, Sosa was transitioned into waist chains upon leaving his

cell.

On March 18, 2020, the district court denied Sosa's

February 2019 motion for a preliminary injunction "in the interest

5 Sosa is usually not held in rear restraints when he is making use of a given facility. For example, while receiving medical treatment in the triage room, he would be transitioned into waist chains. When he is taken to the shower, which has a cell door with a wicket, his handcuffs are taken off and he is not restrained while showering. 6 For example, the DOC represented to the district court that Sosa is allowed to shower at least three times a week.

- 11 - of docket management," and informed counsel that it would "construe

[Sosa's March 2020 motion] as a motion for preliminary injunction."

Sosa v. Mass. Dep't of Corr.,

, 38 (2020). We

understand the district court to have thereby consolidated the

requests for relief in Sosa's February 2019 and March 2020 motions

by treating Sosa's March 2020 motion as a motion for a preliminary

injunction seeking an order compelling the DOC and other

defendants: (1) to stop rear cuffing him with single handcuffs;

(2) to further lengthen the custom handcuffs used to initially

rear cuff him when in his cell, so that the custom handcuffs are

at least three inches longer than double cuffs; and (3) to

transition him from rear cuffs to waist chains whenever he is

removed from his cell, including when he is only being moved within

the BMU.7

In a status report filed the following month, the DOC

explained that it had been unable to consult with Dr. Elman about

the appropriate span for the custom handcuffs, citing the lockdown

of all DOC correctional institutions as a response to the COVID-

7 Against this characterization of the district court's denial of Sosa's February 2019 motion as a consolidation of both his February 2019 and March 2020 motions for reasons of administrative convenience, appellees contend that the district court was rejecting Sosa's earlier motion on its merits. But this interpretation of the district court's denial of Sosa's earlier pro se motion is difficult to square with the court's subsequent indication that it had denied that motion "in the interest of docket management." Sosa, 494 F. Supp. 3d at 38.

- 12 - 19 pandemic. To avoid further delays, the DOC had therefore, on

its own initiative, ordered a set of double cuffs-length handcuffs

to be manufactured.

By July 2020, when the district court held another status

conference, the DOC reported further delays in obtaining a medical

opinion from Dr. Elman because of continued COVID-19 restrictions

on entry into its facilities. In response, the court allowed the

DOC to consult with Dr. Frank, a different independent physician.8

The DOC also reported that, since May 2020, it had begun

restraining Sosa with the double cuffs-length custom handcuffs it

had ordered to be manufactured. These custom handcuffs were, the

DOC insisted, at the maximum length consistent with institutional

security needs. At the status conference, the DOC's counsel also

represented to the court that it was opposed to transitioning Sosa

into waist chains when being moved within the BMU because it was

"not . . . efficient" to transition him repeatedly between rear

restraints and waist chains every time he was taken to the shower

or other facilities within the BMU, particularly given the very

short distances involved. At the same time, the DOC's counsel

conceded that securing Sosa with waist chains presented no

"security risk" and that waist chains "provide security."

8This physician was independent in virtue of his employment by the Department of Public Health, rather than the DOC.

- 13 - In late September 2020, a medical assessment of the

impact on his shoulders of restraining Sosa using double cuffs-

length handcuffs was finally conducted via telemedicine by a

physician assistant working for Lemuel Shattuck Hospital. The

report issued following this assessment stated that Sosa's

shoulders retained 30 and 40 degrees of internal rotation in

abduction on the left and right respectively. The report further

stated that the double cuffs-length custom handcuffs internally

rotated Sosa's shoulders about 20 degrees on each side.

Restraining Sosa using the custom handcuffs therefore rotated and

stretched his shoulders less than would standard handcuffs. Hence,

the report concluded, the double cuffs-length handcuffs "reduce[d]

somewhat" the pain Sosa experienced from rear cuffing compared to

the application of standard handcuffs. Nevertheless, the report

also indicated that Sosa still found rear cuffing with the custom

handcuffs "painful."

On October 2, 2020, the district court held a status

conference at which the DOC represented to the court that, when

Sosa is moved within the BMU, he would continue to be rear cuffed

using the double cuffs-length custom handcuffs. The DOC reiterated

its view that further extension of the custom handcuffs would

unacceptably compromise security, because Sosa would then find it

easier, by pulling the handcuff chain under his feet, to maneuver

his hands from his rear to his front, where he would have the range

- 14 - of motion to strike officers and others around him. When the court

drew attention to the September 2020 medical report concluding

that the double cuffs-length custom handcuffs alleviated Sosa's

pain from rear cuffing, his counsel insisted that while the

extended handcuffs did cause less pain, rear cuffing was still

extremely painful if continued for a sustained period of time.

Following this status conference, the district court

allowed in part and denied in part Sosa's March 2020 motion for a

preliminary injunction. Sosa's motion was allowed to the extent

that the DOC was ordered to stop rear cuffing him with standard

single handcuffs. The court also "directed" the DOC to "continue

to use" the double cuffs-length custom handcuffs that "allow[ed]

Mr. Sosa's arms to be shackled at, or just behind, his hips" when

applying rear cuffing, although Sosa had not specifically

requested this relief. Sosa, 494 F. Supp. at 39.

Sosa's motion was denied to the extent that the court

refused to issue a preliminary injunction ordering the DOC to

further alter the procedure used to restrain Sosa for movements

within the BMU by (1) extending the custom handcuffs used to

initially secure him in his cell by an additional three inches or

more, and (2) transitioning him into waist chains once he is taken

out of his cell. As the district court explained, it premised

this denial of relief on the assumption that the DOC would continue

using double cuffs-length custom handcuffs when rear cuffing Sosa.

- 15 - The court based that assumption on its recognition that the DOC

had by then been using those handcuffs "for an extended period of

time," that the DOC had "agreed to continue to use them," and that

the DOC was being "directed" by the court itself to continue to

use them. Sosa, 494 F. Supp. at 39.

Sosa timely appealed from the partial denial of his

requests for preliminary relief.9

II.

A. Standard of review

We have cautioned that "[a] preliminary injunction is an

extraordinary remedy never awarded as of right." Me. Forest Prods.

Council v. Cormier,

(1st Cir. 2022) (quoting Winter

v. Nat. Res. Def. Council, Inc.,

(2008)). To be

granted a preliminary injunction, a plaintiff "must establish" the

following four factors: "that he is likely to succeed on the

merits, that he is likely to suffer irreparable harm in the absence

of preliminary relief, that the balance of equities tips in his

favor, and that an injunction is in the public interest." Dist.

4 Lodge of the Int'l Ass'n of Machinists Loc. Lodge 207 v.

Raimondo,

(1st Cir. 2022) (quoting Winter,

).

9 Only the district court's partial denial of Sosa's request for preliminary relief is before us; the DOC does not challenge the court's partial grant of relief.

- 16 - As a "civil action with respect to prison conditions"

for purposes of the Prison Litigation Reform Act ("PLRA"),

(g)(2), Sosa's pursuit of a preliminary injunction

must also navigate the particular requirements for prospective

relief established by that statute.10 The PLRA defines

"prospective relief" broadly as "all relief other than

compensatory monetary damages." See § 3626(g)(7). Where a

plaintiff in a prison-conditions case seeks prospective relief so

defined, the PLRA bars the allowance of the requested relief unless

it is "narrowly drawn, extends no further than necessary to correct

the violation of the [plaintiff's] Federal right, and is the least

intrusive means necessary to correct the violation of the Federal

right." § 3626(a)(1)(A).

For two reasons, our review of the district court's

denial of preliminary relief focuses on the likelihood that Sosa

will succeed on the merits with his Eighth Amendment and ADA

claims. First, since the PLRA restricts the availability of

prospective relief -- including Sosa's request for preliminary

injunctive relief -- to what is necessary and narrowly drawn to

correct the violation of the plaintiff's federal rights, see Miller

10 The PLRA defines a "civil action with respect to prison conditions" as "any civil proceeding arising under Federal law with respect to the conditions of confinement or the effects of actions by governmental officials on the lives of persons confined in prison." § 3626(g)(2).

- 17 - v. French,

(2000); Crawford v. Clarke,

(1st Cir. 2009), the district court could not have issued

a preliminary injunction consistent with the PLRA's requirements

without first determining that Sosa's federal constitutional and

statutory rights were likely violated.

Second, in denying Sosa's request for preliminary

relief, the district court relied entirely on its negative

assessment of Sosa's likelihood of success on the merits. The

court's sole stated reason for partially denying Sosa's requested

preliminary relief was its conclusion that rear cuffing with double

cuffs-length custom handcuffs -- which was the restraint method

that the DOC had been using, agreed to continue using, and was

being directed by the court to continue to use -- "represent[s] a

reasonable accommodation that avoids a substantial risk of causing

Mr. Sosa undue harm while still allowing the DOC to maintain safety

and security for its officers." Sosa, 494 F. Supp. 3d at 39. We

infer that, with this statement, the court was addressing Sosa's

likelihood of success with both his Eighth Amendment claim and his

ADA claim.

In examining the district court's conclusion that Sosa

was unlikely to succeed on the merits, we review the court's

"rulings on abstract legal issues de novo," and any supporting

"findings of fact for clear error." Dist. 4 Lodge,

(quoting Water Keeper All. v. U.S. Dep't of Def.,

, 30

- 18 - (1st Cir. 2001)). Only having reviewed the court's conclusion

that Sosa was unlikely to prevail on the merits will we test "the

district court's . . . ultimate decision to deny [a] preliminary

injunction for abuse of discretion." Together Emps., v. Mass Gen.

Brigham Inc.,

(1st Cir. 2022) (quoting Does 1-6 v.

Mills,

(1st Cir. 2021)).

Because the court stated the findings and reasoning

underlying its conclusion on the likelihood-of-success factor

tersely, our review sometimes proceeds by inferring the court's

findings and reasoning. Cf. Victim Rights Law Ctr. v. Rosenfelt,

(1st Cir. 2021) ("[The Court of Appeals] offers

deference to the district court's decisionmaking to the extent its

'findings or reasons can be reasonably inferred.'" (quoting Cotter

v. Mass. Ass'n of Minority Law Enf't Officers,

(1st Cir. 2000))). Where "the district court made no specific

findings, we can do so, relying on the record." T-Mobile Ne. LLC

v. Town of Barnstable,

(1st Cir. 2020) (quoting

Geiger v. Foley Hoag LLP Ret. Plan,

(1st Cir.

2008)). Where the district court's reasoning cannot be inferred,

we inquire into whether we "may affirm its order on any independent

ground made apparent by the record." United States v. Castillo-

Martinez,

(1st Cir. 2021) (quoting United States

v. Cabrera-Polo,

(1st Cir. 2004)).

- 19 - B. Likelihood of Success on the Merits

1. Eighth Amendment claim

Sosa contends that, by denying him adequate medical

care, the DOC subjects him to cruel and unusual punishment in

violation of the Eighth Amendment, as made applicable to the states

by the Fourteenth Amendment. See Robinson v. California,

(1962). The medical care at issue, he argues, is the

denial of a restraint method that would reduce the pain he

experiences from being rear cuffed with double cuffs-length custom

handcuffs by first rear cuffing him in his cell with additionally

extended custom handcuffs before transitioning him into waist

chains upon removal from his cell.

We acknowledge that it is unclear whether the restraint

procedure Sosa requests but the DOC refuses to provide qualifies

as medical care. While his requested restraint procedure is

expected to alleviate the pain caused by the interaction of the

challenged restraint procedure with his arthritis, it would not

cure or treat his underlying disease. On the other hand, there is

a recognized medical specialty dedicated to the prevention of pain,

namely pain medicine.11 To the extent that Sosa's requested

11 As the American Academy of Pain Medicine defines this specialty, it is "concerned with the study of pain, prevention of pain, and the evaluation, treatment, and rehabilitation of persons in pain." What Is Pain Medicine?, American Academy of Pain Medicine, https://painmed.org/what-is-pain-medicine/.

- 20 - procedure would alleviate his shoulder pain, it could perhaps be

characterized as a form of medical care falling within this

specialty. We need not decide here whether Sosa's framing of his

Eighth Amendment claim as a denial of adequate medical care is

correct, however, because even if we were to take this framing on

its own terms and assess whether Sosa was denied adequate medical

care, his claim would fail.

Under the Eighth Amendment's prohibition on cruel and

unusual punishment, prison officials "must ensure that inmates

receive adequate . . . medical care." Farmer v. Brennan,

(1994); see also Estelle v. Gamble,

(1976) (explaining that Eighth Amendment principles establish "the

government's obligation to provide medical care for those whom it

is punishing by incarceration."). The inquiry into whether an

inmate has been deprived of constitutionally adequate medical care

has two components, one objective and one subjective.

The objective component requires that the medical needs

of the inmate seeking care be "sufficiently serious." Farmer,

(quoting Wilson v. Seiter,

(1991)).

A medical need is sufficiently serious if it "has been diagnosed

by a physician as mandating treatment," or is "so obvious that

even a lay person would easily recognize the necessity for a

doctor's attention." Zingg v. Groblewski,

(1st

Cir. 2018) (quoting Kosilek v. Spencer,

(1st Cir.

- 21 - 2014). Here, the district court found that Sosa "suffers from a

severe shoulder condition" that reduces the range of motion of his

shoulder joints. Sosa, 494 F. Supp. 3d at 38. The court could

therefore properly have concluded -- and the parties do not dispute

-- that Sosa has a medical condition that is sufficiently serious

for purposes of the objective component of the inadequate medical

care inquiry.

Subjectively, prison officials must possess a

"sufficiently culpable state of mind" amounting to "deliberate

indifference to the [inmate's] health or safety." Zingg,

(citing Perry v. Roy,

(1st Cir. 2015)). To

meet the deliberate indifference standard, prison officials must

either deny "needed medical treatment in order to punish the

inmate," or display "'wanton' or criminal recklessness in the

treatment afforded."

(quoting Watson v. Caton,

(1st Cir. 1993)). In other words, an official who "knows of

and disregards an excessive risk to inmate health" is deliberately

indifferent. Farmer,

. This deliberate

indifference can include conscious and unjustified failure to

relieve an inmate's physical pain. See Hudson v. McMillian,

(1992) ("[T]he unnecessary and wanton infliction of pain

. . . constitutes cruel and unusual punishment forbidden by the

Eighth Amendment." (quoting Whitley v. Albers,

(1986)); Kosilek,

(citing Estelle,

)

- 22 - ("Undue suffering, unrelated to any legitimate penological

purpose, is considered a form of punishment proscribed by the

Eighth Amendment.").

Crucially, however, prison officials lack the culpable

mental state required for Eighth Amendment liability where, having

actual knowledge of a "substantial risk to inmate health," they

"respond[] reasonably to the risk." Farmer,

; see

also Kosilek,

. Whether a given response to a

substantial risk to inmate health is reasonable depends on whether

it appropriately balances "security and administrative concerns,"

Cameron v. Tomes,

(1st Cir. 1993), with meeting

the inmate's medical needs. For this reason, even an outright

"denial of care" may not evince deliberate indifference if that

decision is sufficiently justified by "legitimate concerns" of

prison administration such as "institutional security." Kosilek,

; see also Battista v. Clarke,

(1st Cir. 2011) (explaining that if prison officials' "balancing

judgments" between inmate medical need and "security

considerations" are "within the realm of reason and made in good

faith," withholding of desired medical care is not deliberate

indifference).

Here, the district court stated that, in rear cuffing

Sosa with custom-made double cuffs-length handcuffs, the DOC

framed a "reasonable accommodation" that "avoid[ed] a substantial

- 23 - risk of causing [him] undue harm" while also "maintain[ing] safety

and security for its officers." Sosa, 494 F. Supp. 3d at 39. We

infer from this language that the court reasoned that there was no

deliberate indifference under Farmer,

, because the

custom handcuffs represented a reasonable response to Sosa's

medical needs. And because he would therefore be unable to

establish the subjective component of his inadequate medical care

claim, the court concluded that he was unlikely to succeed in

establishing that claim on the merits.

On appeal, Sosa argues that the restraint procedure used

by the DOC does in fact evince deliberate indifference because it

does not reasonably balance the risk of pain to him with the

legitimate concerns of prison administration. On the one hand,

due to his shoulder condition, any restraint method other than

those allowing Sosa's arms to hang at the sides -- such as his

requested restraint procedure -- caused him significant pain. On

the other hand, there was no genuine security reason not to

transition him to waist chains when transported out of his cell,

since the only reason cited was the inadequate justification of

avoiding inconvenience to prison personnel. As such, restraining

him for movements within the BMU by rear cuffing with double cuffs-

length custom handcuffs amounted to deliberate indifference to his

shoulder pain.

- 24 - First, we address Sosa's contention that rear cuffing

him with double cuffs-length handcuffs continues to inflict

significant pain. We infer from the district court's statement

that the DOC's modified cuffing procedure "avoid[ed] a substantial

risk of causing Mr. Sosa undue harm," Sosa, 494 F. Supp. 3d at 39,

that the court found that whatever residual pain Sosa suffered,

the modified procedure substantially relieved the pain he

previously experienced from rear cuffing with standard single

handcuffs. In making this finding, the court apparently relied,

in particular, on two pieces of evidence. First, there was the

medical report issued after Sosa's September 2020 medical

evaluation, which concluded that rear cuffing with the custom

handcuffs "reduce[d] the rotation and stretching" of Sosa's

shoulders, which "alleviate[d] to some degree the pain" he

experienced. Id. at 38. Second, there was Sosa's own

"conce[ssion] that the custom handcuffs significantly reduced the

pain" to his shoulders. Id.

Our review of the record reveals no clear error in the

district court's factual finding that Sosa experienced

significantly less pain from rear cuffing with double cuffs-length

custom handcuffs than he did with standard single handcuffs.

According to the medical report the district court relied on, rear

cuffing with the custom handcuffs caused internal shoulder

rotation only within his shoulders' remaining range of motion,

- 25 - thereby reducing -- even if not completely eliminating -- his

shoulder pain. Moreover, Sosa himself represented to the district

court that "[t]he double handcuff behind the back has been a

Godsend" that "helped alleviate" his pain "a great deal."

To be sure, Sosa has attested in an affidavit that the

DOC's modified rear cuffing procedure was "still painful."

However, as appellees emphasize and the record confirms, the period

of time that Sosa spent in rear cuffs each time he was moved within

the BMU was very brief: it took four minutes at most to travel

between his cell and other facilities within the BMU, and he was

generally not kept in rear restraints once securely in the shower,

triage room, or other facilities within the BMU. Because Sosa was

only held in rear cuffs for brief periods each time, any pain he

experienced was therefore limited. We infer that the district

court took the brevity of the pain Sosa experienced into

consideration in making its determination that the DOC's use of

double cuffs-length custom handcuffs was a reasonable response to

Sosa's complaints of pain from rear cuffing.

Importantly, the presence of reduced residual pain for

a limited period of time implicates the Supreme Court's

pronouncement that the response of prison officials to a threat to

inmate health may be reasonable "even if the harm ultimately was

not averted." Farmer,

. In the context of

evaluating the reasonableness of the response of prison officials

- 26 - to inmate pain, we have explained that it is only "[u]ndue

suffering" -- that is, suffering serving no "legitimate

penological purpose" -- that the Eighth Amendment forbids. See

Kosilek,

(emphasis added) (citing Estelle,

).

Hence, the question whether the DOC reasonably refused

to adopt Sosa's requested restraint procedure crucially depends on

whether his desired procedure would compromise legitimate

penological objectives. We infer from the court's reference to

the DOC's interest in "maintain[ing] safety and security for its

officers," Sosa, 494 F. Supp. 3d at 39, that it found that the use

of additionally extended custom handcuffs to restrain Sosa posed

a genuine and significant risk to institutional security, the

maintenance of which is "perhaps the most legitimate of penological

goals." Overton v. Bazzetta,

(2003).

We discern no clear error in the district court's factual

finding that there was a legitimate security risk, which is amply

supported by the record. The DOC twice represented to the court

that additional extension of the custom handcuffs beyond double

cuffs-length would compromise security. With a longer handcuff

chain, Sosa would more easily be able to maneuver his hands from

behind him to his front, enabling him to strike officers more

easily. The DOC's fear that Sosa might attack officers was well-

founded, given his lengthy history of violent infractions of prison

- 27 - discipline. And, given the finding that additional extension of

the custom handcuffs would significantly compromise security, the

district court could properly have concluded that security

concerns justified refusing Sosa's requested extension.

We review next the district court's related and implied

determination that the DOC reasonably refused to transition Sosa

into waist chains whenever he is moved from his cell to another

location within the BMU. While Sosa contends that there is no

genuine security justification for the DOC's refusal, and that the

real motivation for this decision was an inadequate efficiency

concern, the record discloses genuine security interests that

support the reasonableness of the DOC's decision.

As the DOC explained to the district court, the security

concerns surrounding any routine transitioning of Sosa to waist

chains arise from the dangers inherent in the moments of transition

themselves, when officers are vulnerable. Since Sosa makes use of

facilities within the BMU multiple times a week,12 if he must be

transitioned into waist chains each time he is removed from his

cell, prison officers will frequently be exposed to danger during

the numerous moments of transition. Thus, there is ample support

in the record for the district court's implied finding that

routinely transitioning Sosa into waist chains would compromise

12 Indeed, Sosa himself contends that he is rear cuffed to move around the BMU "on an almost daily basis."

- 28 - the "safety and security of [DOC] officers."13 Sosa, 494 F. Supp.

3d at 39.

In sum, the district court properly concluded that (1)

the DOC responded reasonably to Sosa's shoulder pain in adopting

a modified rear cuffing procedure using double cuffs-length custom

handcuffs, rather than using his requested restraint method, and

(2) for that reason, Sosa is unlikely to succeed with his Eighth

Amendment claim that appellees inflicted cruel and unusual

punishment through deliberate indifference to his medical needs.

2. ADA claim

Under Title II of the ADA, a "qualified individual with

a disability" shall not, "by reason of" that disability, be

"excluded from participation in or be denied the benefits of the

services, programs, or activities" provided by a "public entity,"

or otherwise "be subjected to discrimination" by such an entity.

. State prisons are public entities for Title II

purposes. See United States v. Georgia,

(2006);

Pa. Dep't of Corrs. v. Yeskey,

(1998). To

establish a prima facie case of a Title II violation, a plaintiff

13 The DOC counsel's statement to the district court that waist chains "provide security" does not undermine this finding. There is no inconsistency between (1) the factual assertion that when Sosa is already being restrained with waist chains, he is sufficiently secured to provide security and (2) the factual assertion that Sosa poses a security risk in the moment of transition from rear cuffs to waist chains -- that is, before he has been fully secured with waist chains.

- 29 - must show that: (1) he is a "qualified individual with a

disability"; (2) he was "excluded from participation in, or denied

the benefits of a public entity's services, programs, or activities

or was otherwise discriminated against"; and (3) this exclusion,

denial of benefits, or discrimination was "by reason of [his]

disability." Snell v. Neville,

(1st Cir. 2021)

(quoting Kiman v. N.H. Dep't of Corrs.,

(1st

Cir. 2006)).

Courts have recognized that a claim under Title II may

be premised on one of three theories of discrimination: (1)

intentional discrimination or disparate treatment; (2) failure to

make a reasonable accommodation; (3) disparate impact. See, e.g.,

Richardson v. Clarke,

(4th Cir. 2022); Payan v.

L.A. Cmty. Coll. Dist.,

, 738 (9th Cir. 2021); Hamilton

v. Westchester Cnty.,

(2d Cir. 2021).

An intentional discrimination Title II claim alleges

"outright intentional exclusion" from opportunities, which

Congress found to be one of the "forms of discrimination" that

individuals with disabilities "continually encounter."

(a)(5). But Congress also recognized that the "failure to

make modifications to existing . . . practices" can also be a form

of discrimination against individuals with disabilities,

since facially neutral practices and policies will often specially

- 30 - burden particular individuals with disabilities with respect to

accessing opportunities.

For this reason, public entities are required under

Title II to "make reasonable modifications" in their "policies,

practices, or procedures" if these are "necessary to avoid

discrimination on the basis of disability."

(b)(7)(i). However, a public entity is not required to

make modifications that would "fundamentally alter the nature of"

the services, programs, and activities it provides,

or that

would impose on it an "undue burden," Toledo v. Sanchez,

(1st Cir. 2006). A Title II claim premised on a failure to

provide a reasonable accommodation -- or, in other terminology, to

make reasonable modifications14 -- thus alleges that: (1) due to

the claimant's disability, he needs an individualized change to a

public entity's facially neutral policies, practices, or

procedures if he is to effectively access some opportunity; but

(2) the public entity unjustifiably failed to make that change.

See Payan, 11 F.4th at 738.

Finally, a disparate impact Title II claim is closely

related to a reasonable accommodation claim, in that both theories

14 While Title II of the ADA uses the term "reasonable modifications" and Title I uses the more familiar term "reasonable accommodation," these terms are often used interchangeably. See Payan, 11 F.4th at 738 n.4; Pollack v. Reg'l Sch. Unit 75,

, 80 n.3 (1st Cir. 2018).

- 31 - of disability discrimination allege that a public entity's

facially neutral rule specially burdens disabled individuals'

meaningful access to a public service, program, or activity, or

some other opportunity, and both seek a reasonable modification in

the facially neutral rule to alleviate that burden. See

The

key difference between these two theories is that a reasonable

accommodation claim focuses on "an individualized request or need"

for a reasonable modification, while a disparate impact claim

alleges a more "systemic" obstacle to access.

Sosa premises his ADA claim on a reasonable

accommodation theory. He contends that his requested restraint

procedure, because it would alleviate the restraint-induced pain

in his arthritic shoulders, constitutes medical care. Medical

care is, we have recognized, a "service, program, or activity"

covered by Title II. See Kiman,

. He also argues

that, because his requested restraint procedure would alleviate

the remaining shoulder pain he suffers without creating any genuine

security risk, that procedure represents a reasonable modification

or accommodation. By failing to reasonably modify its restraint

procedures in the way he requests, then, the DOC effectively

excluded him from medical care in violation of Title II.

In asserting that his requested restraint procedure does

not create a genuine security risk and is therefore a reasonable

accommodation, Sosa is disputing the district court's implied

- 32 - factual findings and its legal conclusions regarding his ADA claim.

We infer from the language of the court's order that it found that

Sosa's requested restraint procedure would compromise

institutional security, whereas rear cuffing him using the custom-

made double cuffs-length handcuffs would "maintain[] safety and

security" while also easing his shoulder pain. Sosa, 494 F. Supp.

3d at 39. For that reason, the DOC's use of the custom handcuffs

was a "reasonable accommodation," and, accordingly, the DOC did

not subject Sosa to disability discrimination by failing to provide

him with a reasonable accommodation. Id.

Echoing the district court, appellees insist that Sosa's

requested restraint method would not be a "reasonable"

modification because it would compromise institutional security.

Since the double cuffs-length custom handcuffs alleviate Sosa's

shoulder pain without creating an unacceptable security risk,

appellees contend, that restraint procedure already provides him

with a reasonable accommodation for his disability.

We begin our review of the district court's treatment of

Sosa's ADA claim by noting some difficulties in the way that Sosa

frames his claim. First, as we discussed in connection with his

Eighth Amendment claim, it is uncertain whether Sosa's requested

restraint procedure can properly qualify as medical care. Second,

Sosa's framing of his ADA claim appears circular. The "service,

program, or activity" from which he alleges that he has been

- 33 - effectively excluded is identical to the reasonable accommodation

that he needs to achieve meaningful access to that "service,

program, or activity": both are the specific modification in the

standard BMU restraint procedure he requests.

We illustrate the poor fit of Sosa's framing with the

reasonable accommodation theory of disability discrimination by

comparing Sosa's framing of his claim with another reasonable

accommodation claim made in the prison context that we considered

in Kiman,

. In that case, an inmate in a New Hampshire

state prison, Matthew Kiman, suffered cramping in his shoulder

muscles which caused him pain when he was subject to rear cuffing.

. He alleged that the pain he experienced from rear

cuffing "affected his access to a variety of the 'services,

programs, or activities' covered by Title II of the ADA."

at

288-89 (quoting

). To achieve meaningful access

to various services, programs, and activities within the prison,

therefore, Kiman needed a reasonable accommodation in the form of

a modified restraint procedure, namely front cuffing. The prison's

failure to use front cuffing to restrain him was therefore, he

urged, disability discrimination in violation of Title II.

By contrast, Sosa does not allege that his shoulder pain impedes

him from accessing the kind of prison services, programs, and

activities that Kiman sought access to. Instead, he argues that

his requested restraint procedure is itself a "service, program,

- 34 - or activity" under Title II to which he lacks meaningful access,

while also maintaining that this modified restraint procedure is

a reasonable accommodation that he needs to achieve that meaningful

access.

For the purposes of this appeal, we choose to ignore

these serious difficulties in Sosa's framing of his ADA claim and

follow the district court in evaluating that claim under a

reasonable accommodation theory, because we conclude that, even on

its own terms, his claim still fails.

"[T]he determination of whether a particular

modification is 'reasonable' involves a fact-specific, case-by-

case inquiry that considers, among other factors, the

effectiveness of the modification in light of the nature of the

disability in question and the cost to the organization that would

implement it." Mary Jo C. v. N.Y. State & Loc. Ret. Sys.,

(2d Cir. 2013) (quoting Staron v. McDonald's Corp.,

(2d Cir. 1995)). A modification is not

"reasonable" if it would "result in a fundamental alteration of

[the service provided by the public entity] or impose an undue

burden." Toledo,

(citing Parker v. Universidad de

P.R.,

(1st Cir. 2000)). Moreover, "[t]erms like

'reasonable' and 'undue' are relative to circumstances," and the

circumstances of a prison that we are faced with here are

"different from those of a school, an office, or a factory."

- 35 - Crawford v. Ind. Dep't of Corrs.,

(7th Cir.

1997). Specifically, "security concerns . . . are highly relevant

to determining the feasibility of the accommodations that disabled

prisoners need in order to have access to desired programs and

services."

Here, as we have already explained, the record supports

the district court's implied finding that Sosa's requested

restraint procedure poses a significant risk to institutional

security. While additional extension of the custom handcuffs and

the use of waist chains would alleviate Sosa's residual pain, the

security risk created by these restraint procedures mean that they

are not "reasonable" modifications. In refusing to adopt Sosa's

requested restraint procedure, then, the DOC did not subject him

to disability discrimination by failing to provide a reasonable

accommodation.

III.

The district court correctly determined that Sosa is

unlikely to succeed on the merits of his Eighth Amendment claim,

because the DOC responded reasonably to his medical needs, belying

any claim of deliberate indifference. The district court also

properly concluded that Sosa is unlikely to prevail on the merits

of his ADA claim, because the DOC's refusal to adopt his requested

restraint procedure did not fail to provide him with a reasonable

accommodation for his shoulder pain. Hence, the district court

- 36 - did not abuse its discretion in partially denying Sosa's request

for preliminary relief.

Affirmed.

- 37 -