Low back pain is a leading cause of disability worldwide. It is one of the leading reasons for presentation to the emergency department (ED); e.g. in the United States there are over 4 million presentations per year. However, its management in this setting has received relatively little attention and there have been few efforts to develop strategies to improve care and outcomes for people who present to ED with low back pain. Interestingly while there are dozens of guidelines to inform management of low back pain in primary care, there are no guidelines specific to the ED setting. While it may be tempting to adopt primary care guidelines for use in the ED; new research would suggest that this may not be wise. This talk will share my own and others’ research to demonstrate that low back pain patients in ED differ to those seen in primary care e.g in terms of mode of arrival, case mix, care received, severity of symptoms and clinical course. It will also highlight the paucity of clinical trials that have studied care delivered in the ED setting. However, despite these challenges the ED setting does offer considerable opportunities for low back pain research; partly because so little has been done, but also because of the easy access to large numbers of patients and the ability to harvest data from the electronic medical records. To illustrate the potential for research I will share the experience of conducting the SHaPED tial (n= 4,625 patients) across four EDs in NSW.