Background Low back pain clinical practice guidelines consistently recommend against the routine ordering of spinal imaging; however, imaging is frequently requested in primary care, without evidence of benefit. Imaging reports frequently identify degenerative features which are likely to be interpreted as ‘abnormal’, despite their high prevalence in symptom-free individuals. The aim of this study was to investigate whether post-imaging back-related perceptions are influenced by providing prior information about normal findings, and to compare the effect of receiving imaging results with best practice care (without imaging). The impact of introducing novel, ‘enhanced’ reporting strategies was also explored. Methods This study was a simulated-patient, randomised, multiple-arm experiment. Patient scenarios were presented to volunteer healthy adult participants via an online survey. In the scenarios, ‘virtual’ patients with low back pain were randomised to one of three groups. Group 1 received imaging and was pre-informed about normal findings. Group 2 received imaging (without pre-information). Group 3 received best practice care: quality information without imaging. Group 1 was further divided to receive either a standard report, or an ‘enhanced’ report (containing altered terminology and epidemiological information). The primary outcome was back-related perceptions (BRP), a composite score derived from three numeric rating scale scores exploring perceptions of spinal condition, recovery concerns and planned activity. The secondary outcomes were satisfaction and kinesiophobia. Results Full data were available from 660 participants (68% female). Analysis of covariance revealed a significant effect of group after controlling for baseline BRP scores $(F(2,74)=10.4,p\lt 0.001,{\eta }_{p}^{2}=.04)$ F 2 , 74 = 10 . 4 , p < 0 . 001 , η p 2 = . 04 . Pairwise comparisons indicated that receiving best practice care resulted in more positive BRPs than receiving imaging results, and receiving prior information about normal findings had no impact. Enhanced reporting strategies also positively impacted BRPs $(F(1,275)=13.06,p\lt 0.001,{\eta }_{p}^{2}=.05)$ F 1 , 275 = 13 . 06 , p < 0 . 001 , η p 2 = . 05 . Significant relationships between group allocation and both satisfaction $(F(2,553)=7.5,p=0.001,{\eta }_{p}^{2}=.03)$ F 2 , 553 = 7 . 5 , p = 0 . 001 , η p 2 = . 03 and kinaesiophobia $(F(2,553)=3.0,p=0.050,{\eta }_{p}^{2}=.01)$ F 2 , 553 = 3 . 0 , p = 0 . 050 , η p 2 = . 01 were found, with statistically significant pairwise comparisions again in favour of best-practice care. Conclusion Intervention strategies such as enhanced reporting methods and the provision of quality information (without imaging) have the potential to improve the outcome of patients with recent-onset LBP and should be further considered by primary care providers.